DR.  U.  G.  LITTELL 

OSTEOPATHIC  PHYSICIAN 

317-18  NEW  SPURQEOri  BLDG. 

HotirB.  9  to  12. 2  to  4.  SANTA  ANA,  CAL 

APR  9    1917 


Digitized  by  tine  Internet  Arciiive 

in  2007  witii  funding  from 

IVIicrosoft  Corporation 


http://www.arcliiye.org/details/clinicalosteopatOOmccoiala 


PUBLICATIONS  OF  ' 
THE  A.  T.  STILL  RESEARCH  INSTITUTE 


(clinical  Osteopathy 

Produced  by 

The  Education  Department 

WITH  A  LARGE  CORPS  OF  WRITERS  AND  CONTRIBUTORS 


Edited  by 

CARL    P.    McCONNELL 


CHICAGO,  ILLINOIS 
1917 


WB  9.4  0 

11  n 


V  Copyright,  1917 

by 
Thb  a.  T.  Stiix  Research  Institute 


Preface 

The  present  period  of  medical  history  is  characterized  by  def- 
inite development  of  the  medical  sciences.  There  is  probably  not 
a  field  that  has  not  contributed  distinct  and  exact  data  toward  the 
evolvement  of  the  practice  of  the  healing  art.  The  prosecution  of 
sanitary  knowledge  has  been  noteworthy.  The  far  better  under- 
standing of  infective  processes  and  the  significance  of  immunology 
has  fairly  revolutionized  certain  practices.  The  appreciation  of 
the  importance  of  the  endocrine  organs  in  their  relationship  to 
the  entire  bodily  economy  has  changed  the  viewpoint  of  many 
disorders.  The  far  better  understanding  of  the  functions  of  the 
digestive  tract  due  to  more  definite  diagnostic  methods  has  been 
of  great  value.  These  are  ^  few  of  the  present  landmarks  that 
have  virtually  changed  the  conception  of  certain  physiological 
processes  and  contributed  precise  methods  to  the  treatment  of 
many  disorders. 

Medical  history  shows  that  it  is  vouchsafed  to  but  very  few 
individuals  to  discover  and  contribute  such  far-reaching  discov- 
eries as  Dr.  Still  has  made.  As  time  reveals  the  many  brilliant 
workers  in  the  scientific  field  the  importance  of  Dr.  Still's  great 
work  is  enhanced.  A  clearer  understanding  of  anatomical  com- 
pleteness and  intactness,  and  the  consequent  significance  of  adjust- 
ment in  order  that  physiological  unity  may  be  asserted  through 
the  inherent  properties  of  the  organism,  is  apparently  foreshad- 
owed by  the  many  converging  lines  of  medical  development. 

It  is  fitting  that  at  this  time  these  coworkers,  in  Clinical  Oste- 
opathy, should  compile,  evaluate  and  rewrite  the  present  under- 
standing of  the  medical  sciences  as  they  apply  to  therapeutics. 
The  osteopathic  profession  is  very  much  in  need  of  such  a  work; 
it  fills  a  distinct  requirement. 

We  believe  that  the  profession  will  take  sufficient  interest  in 
this  work  so  that  it  will  be  constructively  criticised  and  much 
valuable  data  supplied  by  both  teachers  and  practitioners  of  oste- 
opathy in  order  that  future  editions  will  still  better  reflect  the 
combined  experience  of  the  profession.  Unquestionably  every 
practitioner  of  experience  can  aid  most  substantially  and  definitely 

3 


in  adding  to  the  value  of  Clinical  Osteopathy,  and  for  this  reason 
we  bespeak  the  earnest  cooperation  of  every  member  of  the  pro- 
fession. 

Possibly  some  time  in  the  future  a  new  nosology  will  be 
evolved,  for  many  disorders,  based  upon  the  innervation,  vascular 
supply,  and  chemical  coordination  of  a  region,  as  suggested  in  the 
writings  of  Dr.  Still.  In  many  ways  this  would  harmonize  with 
the  osteopathic  concept  of  anatomical  completeness  and  physio- 
logical unification,  and  thus  would  simplify  and  render  more 
effective  etiologic  diagnosis  and  the  fundamentals  of  pathology. 

Far  too  frequently  the  relative  importance  of  history  taking, 
anatomical  findings,  and  laboratory  data  are  not  sufficiently  empha- 
sized in  the  individual  case.  Each  one  of  these  is  an  important 
and  indispensable  link  to  the  solution  of  a  diseased  condition. 
Neglect  one  part  and  the  practitioner  is  distinctly  handicapped  in 
securing  a  clear  understanding  of  the  condition  presented  to  him. 
The  written  word  can  assist  him  comparatively  little  in  the  indi- 
vidual case.  Almost  beyond  everything  else  in  practice  rests  the 
individuation  of  a  diseased  condition.  Ability  and  efficiency  in 
practice,  to  a  marked  extent,  depends  upon  the  evaluation  of  the 
various  factors  presented,  based  of  course  upon  definite  funda- 
mentals, but  nevertheless  interpreted  in  accordance  with  a  distinct 
appreciation  of  the  individual  vital  organism. 

Probably  in  no  other  practice  than  the  osteopathic  does  per- 
sonal therapeutic  ability  count  for  so  much.  Osteopathy  exempli- 
fies a  distinct  advance  of  the  knowledge  of  the  healing  art,  based 
primarily  upon  the  etiologic  diagnosis  of  many  disorders,  and  as  a 
consequence  technical  efficiency  is  dependent  upon  a  high  degree 
of  skill  and  extended  experience.  This  is  something  that  cannot 
possibly  be  learned  from  text-books  but  demands  the  careful  and 
painstaking  instruction  of  sympathetic  teachers,  over  a  consid- 
erable period  of  time. 

Carl  P.  McConnell. 


Publisher's  Announcement 

This  book  is  the  first  of  a  series  being  prepared  under  the  aus- 
pices of  the  Education  Department  of  the  A.  T.  Still  Research 
Institute,  by  the  cooperation  of  osteopathic  practitioners  and 
teachers  in  osteopathic  colleges.  The  material  for  this  volume 
was  gathered  from  many  sources,  including  osteopathic  publica- 
tions, reports  of  lectures  and  clinics  from  national,  state  and  local 
associations,  several  thousands  of  case  reports  from  the  Pacific 
College  clinics  and  laboratories  and  correspondence  and  consulta- 
tion with  several  hundred  osteopathic  physicians.  The  writings  of 
Dr.  A.  T.  Still  were  constantly  consulted.  Other  books"  frequently 
quoted  include  "Practice  of  Osteopathy,"  by  McConnell  and  Teall ; 
"Practice  of  Osteopathy,"  by  Chas.  Hazzard;  "Principles  of  Oste- 
opathy," by  Guy  D.  Hulett ;  "Principles  of  Osteopathy,"  by  D.  L. 
Tasker;  and  "Public  Sanitation  and  Other  Papers,"  by  Clement 
A.  Whiting. 

The  names  of  those  whose  contributions  and  criticisms  have 
made  this  work  possible  are  given.  While  the  greatest  care  has 
been  taken  to  include  all  who  have  helped  in  this  work,  it  may  be 
possible  that  some  have  been  inadvertently  omitted.  In  a  general 
way,  everyone  who  has  ever  written  upon  osteopathic  subjects, 
or  who  has  given  lectures,  has  helped  to  some  extent  in  this  work. 

Other  books  are  being  prepared  in  about  the  same  way,  upon 
other  subjects  and  with  other  editors.  It  is  urgently  desired  that 
with  the  advancement  of  osteopathic  thought,  there  may  be  ad- 
vancement of  osteopathic  literature. 

Publication   Bureau, 
Thb  A.  T.  Stii.1.  Research  Institute. 


CONTENTS 


Part  I — Diseases  of  the  Digestive  System 

CHAPTER  I 

Diseases  of  the  Mouth  and  Salivary  Glands 16 

Stomatitis;  Glossitis;  Leukoplakia  Buccalis;  Cheilitis; 
Pyorrhea  Alveolaris;  Parotitis. 

CHAPTER  II 

Diseases  of  the  Esophagus 29 

Esophagi tis;  Carcinoma;  Stricture;  Dilatation;  Foreign 
Bodies. 

CHAPTER  III 

Neuroses  of  the  Stomach  33 

Hyperchlorhydria ;  Hypochlorhydria;  Hsrpersecretion ; 
Gastralgia;  Bulimia;  Anorexia;  Hyperesthesia;  Super- 
motility;  Vomiting;  Eructations;  Spasm. 

CHAPTER  IV 

Organic  Diseases  of  the  Stomach  ■.         38 

Gastritis;  Gastric  and  Duodenal  Ulcer;  Cancer;  Dilata- 
tion. 

CHAPTER  V 

Diseases  of  the  Intestines  54 

Diarrhea;  Intestinal  Neuroses;  Colic;  Constipation;  In- 
testinal Autointoxication. 

CHAPTER  VI 

Diseases  of  the  Intestines  (Continued)  68 

Gastro-enteroptosis ;  Dilatation;  Acute  Intestinal  Ob- 
struction; Hernia;  Strictures;  Chronic  Obstruction; 
Tumors. 

CHAPTER  VII 

Enteritis  of  Children 79 

Irritative  Enteritis;  Fermental  Enteritis;  Infectious 
Enteritis;  Chronic  Entero-colitis ;  Celiac  Affection. 

CHAPTER  VIII 

Intestinal  Inflammations  of  Adults 90 

Enteritis;  Colitis;  Appendicitis;  Chronic  Entero-Colitis; 
Proctitis. 

6 


CHAPTER  IX 

Diseases  of  the  Liver 103 

Jaundice;  Hyperemia;  Acute  Yellow  Atrophy;  Hepatitis; 
Cirrhosis;  Abscess;  Hydatid  Cyst;  Cancer;  Fatty  Liver. 

CHAPTER  X 

Diseases  of  the  Gail-Bladder  and  Bile  Ducts 115 

Cholangitis;  Cholecystitis;  Gallstones;  Cancer. 

CHAPTER  XI 

Diseases  of  the  Pancreas 123 

Hemorrhage;   Pancreatitis;   Cysts;   Cancer;   Calculi. 

CHAPTER  XII 

Diseases  of  the  Peritoneum 128 

Ascites;  Peritonitis;  Cancer. 


Part  II — Diseases  of  the  Circulatory  System 

CHAPTER  XIII 

Diseases  of  the  Pericardium • 135 

Pericarditis ;  Hydropericardium ;  Hemopericardium. 

CHAPTER  XIV 

Diseases  of  the  Myocardium 141 

Myocarditis;  Fatty  Infiltration;  Fatty  Degeneration; 
Hypertrophy;  Injuries;  Neoplasms;  Aneurysm  of  the 
Heart;  Disease  of  the  Coronary  Arteries;  Angina  Pec- 
toris. 

CHAPTER  XV 

The  Cardiac  Neuroses 153 

Bradycardia;  Tachycardia;  Arrythmia;  Stokes-Adams 
Disease;  Cardiac  Asthma. 

CHAPTER  XVI 

Diseases  of  the  Endocardium  158 

Endocarditis;  Valvular  Lesions. 

CHAPTER  XVII 

Diseases  of  the  Blood  Vessels 171 

Arteriosclerosis;  Aneurysm;  Varicose  Veins;  Varicose 
Ulcers;  Epistaxis. 


Part  III — Diseases  of  the  Respiratory  Tract 

CHAPTER  XVIII 

Diseases  of  the  Nose -. 183 

Rhinitis;  Hay  Fever, 

7 


CHAPTER  XIX 

Adenoids  and  Tonsils 188 

Tonsillitis;  Abscess;  Adenoids. 

CHAPTER  XX 

Diseases  of  the  Pharynx  and  Larynx 194 

Pharyngitis;  Larjmgitis;  Croup. 

CHAPTER  XXI 

Diseases  of  the  Bronchi 205 

Bronchitis;  Bronchiectasis;  Bronchial  Asthma;  Broncho- 
Pneumonia. 

CHAPTER  XXII 

Diseases  of  the  Lungs 215 

Congestion  of  the  Lungs;  Hemorrhage;  Apoplexy; 
Edema;  Collapse;  Emphysema;  Gangrene;  Abscess; 
Pneumokoniosis ;  Pleurisy;  Pneumothorax;  Hydro- 
thorax. 


Part  IV— Diseases  of  the  Blood 

CHAPTER  XXIII 

The   Anemias 229 

Secondary  Anemia;  Costogenic  Anemia;  Chlorosis; 
Hemolytic  Anemia;  Infantile  Anemia;  Splenic  Anemia; 
Gaucher's  Disease;  Polycythemia;  Chloroma. 

CHAPTER  XXIV 

The  Leukemias  240 

Lymphatic  Leukemia;  Myelogenous  Leukemia;  Hodg- 
kin's  Disease. 


Part  V — Diseases  of  the  Urinary  System 

CHAPTER  XXV 

Diseases  of  the  Kidneys 247 

Hyperemia;  Nephritis;  Pyelitis;  Calculus;  Hydronephro- 
sis; Floating  Kidney;  Neoplasms;  Cystic  Kidney;  Em- 
bolism. 

CHAPTER  XXVI 

Diseases  of  the  Bladder 264 

Neuroses;  Enuresis;  Cystitis;  Neoplasms;  Hemorrhages; 
Diseases  of  the  Urethra;  Diseases  of  the  Prostate. 


Part  VI — The  Toxic  and  Constitutional  Diseases 

CHAPTER  XXVII 

Gout  and  Rheumatism  .■ 270 

Gout;  Muscular  Rheumatism;  Chronic  Arthritides. 

8 


CHAPTER  XXVIII 

Disturbances  of  Metabolism  279 

Diabetes      Mellitus;      Diabetes      Insipidus;     Acidosis; 
Rachitis;  Scorbutus;  Infantile  Scurvy;  Obesity. 

CHAPTER  XXIX 
Diseases  of  the  Ductless  Glands  294 

Thyroiditis;  Goiter;  Myxedema  and  Cretinism;  Diseases 

of  the  Parathyroids;   Tetany;   Disease  of  the   Pituitary 

Body;    Acromegaly;    Hypophysis    Adiposity;    Addison's 

Disease. 

CHAPTER  XXX 
Unclassified  Diseases    309 

Purpura;    Hemophilia;    Splenitis;    Status    Lymphaticus; 

Mountain    Sickness;    Seasickness;    Raynaud's    Disease; 

Angio-neurotic    Edema;     Sunstroke;    Heat    Exhaustion;  v 

Snow  Blindness  and  Delirium;  Desert  Sickness;  Simple 

Continued  Fever. 

CHAPTER  XXXI 
Chronic  Drug  Poisonings   322 

Alcoholism;   Morphinism;   Cocainism;   Lead  Poisoning; 

Mercurialism;  Arsenicism;  Headache  Medicines. 

CHAPTER  XXXII 

Food  Poisoning 332 

Pellagra;  Ergotism;  Lathyrism;  Poisoning  from  Mush- 
rooms, Cheese,  Meat,  and  other  Articles  of  Food. 


Part  y II— Diseases  of  the  Nervous  System 

CHAPTER  XXXIII 

Diseases  of  the  Meninges 338 

Pachymeningitis ;  Leptomeningitis. 

CHAPTER  XXXIV 

Diseases  Affecting  Both  Brain  and  Cord 343 

Multiple  Sclerosis;  Locomotor  Ataxia;  Paralytic  De- 
mentia; Disseminated  Myelitis. 

CHAPTER  XXXV 

Diseases  of  the  Spinal  Cord 351 

Hemorrhage;  Myelitis;  Compression;  Meningomyelitis ; 
Syringomyelia;  Caisson  Disease;  Landry's  Paralysis; 
Progressive  Muscular  Atrophy;  Amyotrophic  Lateral 
Sclerosis;  Hereditary  Spinal  Ataxia. 

CHAPTER  XXXVI 

Diseases  of  the  Brain 371 

Anemia;  Hyperemia;  Edema;  Apoplexy;  Delirium  Acu- 
tum;  Senile  Dementia;  Hydrocephalus;  Amaurotic  Fam- 
ily Idiocy;  Cerebral  Paralyses  of  Children;  Lenticular 
Disease;  Brain  Tumor  and  Abscess;  Suppurative  Enceph- 
alitis. 

9 


CHAPTER  XXXVII 

Functional  Neuroses 391 

Hysteria;    Neurasthenia    States;    Traumatic    Neuroses; 
Migraine;  Occupational  Neuroses. 

CHAPTER  XXXVIII 

Neuroses  with  Motor  Symptoms 408 

Epilepsy;  Chorea;  Infantile  Convulsions. 

CHAPTER  XXXIX 

Diseases  of  the  Peripheral  Nerves 424 

Neuralgia;  Neuritis. 

CHAPTER  XL 
Diseases  of  the  Cranial  Nerves 433 


Part  VIII — Diseases  of  the  Skeletal  Muscles 

CHAPTER  XLI 

Diseases  of  Muscles  448 

Polymyositis;  Myositis  Ossificans;  Secondary  Muscular 
Diseases;  Muscular  Dystrophies;  Myotonia  Congenita; 
Pseudo-hjrpertrophic  Muscular  Dystrophy;  Functional 
Motor  Disturbances;  Periodic  Paralysis. 


Part  IX — The  Infectious  Diseases 

CHAPTER  XLII 
Tuberculosis    459 

CHAPTER  XLIII     . 
Leprosy   475 

CHAPTER  XLIV 
Typhoid  and  Typhus 478 

CHAPTER  XLV 
InHuenza,  Whooping  Cough,  Diphtheria 489 

CHAPTER  XLVI 

Diseases  Due  to  Coccus  Infection 500 

Lobar  Pneumonia;  Epidemic  Meningitis;  Infantile  Paral- 
ysis; Erysipelas;  Articular  Rheumatism. 

CHAPTER  XLVII 

Diseases  Due  to  Spirochetes ■ 520 

Relapsing  Fever;  Syphilis.  ^ 

10 


CHAPTER  XLVIII 

Diseases  Due  to  Animal  Associates 529 

Plague;  Hydrophobia;  Tetanus;  Foot  and  Mouth 
Disease;  Actinomycosis;  Milk  Sickness;  Glanders; 
Anthrax. 

CHAPTER  XLIX 

Diseases  Due  to  Agents  Yet  Unknown 540 

Variola;  Vaccinia;  Varicella;  Scarlet  Fever;  Measles; 
Rubella;  Epidemic  Parotitis;  Glandular  Fever. 

CHAPTER  L 

Tropical  Diseases 566 

Beri-Beri;  Febrile  Icterus;  Miliary  Fever;  Yaws; 
Dysentery;  Dengue;  Malta  Fever;  Yellow  Fever; 
Cholera. 


Part  X — Diseases  Due  to  Animal  Parasites 

CHAPTER  LI 

Protozoan  Diseases 581 

Malaria;  Tropical  Splenomegaly;  Leishmaniasis;  Rocky 
Mountain  Fever;  Trypanosomiasis  (Sleeping  Sickness); 
Psorospermiasis ;  Amebic  Dysentery. 

CHAPTER  LII 

Nematodes    593 

Dracontiasis;  Thread  Worms;  Ascaris  Lumbricoides ; 
Filariasis;  Trichiniasis;  Uncinariasis  (Hook-worm 
Disease). 

CHAPTER  LIII 

Trematodes    600 

Distoma. 

CHAPTER  LIV 
Tapeworms  603 


11 


List  of  GontributorSy  Grides  and  Authors  Gonsulted 


Adams,  J.  L. 
Arand,  C.  A. 
Armstrong,  E.  C. 
Ashmore,  Edythe 
Atzen,  C.  B. 
Atzen,  C.  R. 
Bancroft,  C.  M. 
Barnes,  S.  D. 
Bedwell,  W.  H. 
Beeman,  L.  M. 
Bingham,  L.  J. 
Bliss,  Pearl  A. 
Bolles,  Jenette  H. 
Bond,  E.  C. 
Bumpus,  G.  W. 
Burns,  Louisa 
Burns,  M.  L. 
Bush,  Evelyn  R. 
Bush,  L.  M. 
Carpenter,  Ethel  C. 
Carroll,  Margaret 
Carson,  M.  J. 
Cave,  F.  A. 
Cave,  Edith  S. 
Champlain,   C.  A. 
Clarke,  Olive 
Collins,  H.  L. 
Conklin,  H.  W. 
Conley,  G.  J. 
Croftan,  A.  C. 
Croswell,  Mary  S. 
Deason,  J. 
Derek,  J.  E. 
Downing,  E.  M. 
Drinkall,  E.  J. 
Dufur,  J.  I. 
Edmiston,  J.  H. 
Edmiston,  S.  C. 
Edwards,  J.  D. 
Emery,  R.  D. 
Farmer,  F.  C. 
Farnum,  C.  E. 
Feidler,  F.  J. 
Ferguson,  J. 
Ferguson,  Ray  B. 
Fleck,  Chas.  E. 
Foster,  Julia  E. 


Furry,  F.  I. 
Gamble,  H.  W. 
Gerdine,  L.  von  H. 
Gilmour,  Ella  R. 
Goode,  G.  W. 
Goetz,  H.  F. 
Gour,  A.  A. 
Graves,  Millie  B. 
Haight,  L.  L. 
Hamilton,  R.  E. 
Hayden,  W.  J. . 
Hazzard,  Chas. 
Hewes,  C.  G. 
Hibbets,  U.  M. 
Hildreth,  A.  G. 
Hoskins,  Avis  G. 
Hoskins,  E.  R. 
Hudson,  Franklin 
Hulett,  C.  M.  T. 
Hulett,  Guy  D. 
Hunt,  J.  O. 
Hurd,  Nettie  M. 
Ireland,  H.  M. 
Kani,  P.  F. 
Keefer,  F.  E. 
Keene,  W.  B. 
Keyes,  L.  S. 
Laughlin,  Geo.  M. 
Littlejohn,  J.  B, 
Littlejohn,  J.  M. 
Livingston,  L.  R. 
Lockwood,  T.  D. 
Long,  J.  H. 
MacDonald,  J.  A. 
Mack,  W.  B. 
MacGregor,  G.  W. 
McConnell,  C.  P. 
McNary,  J.  F. 
Meacham,  W.  B. 
Millard,  F.  P. 
Moore,  F.  E. 
Moriarty,  J.  J. 
Morris,  F.  W. 
Muttart,  C.  J. 
Nelson,  Lura  B. 
Nicholl,  W.  S. 
Osborne,  O.  T. 


Overton,  J.  A. 
Patterson,  E.  W. 
Pearce,  J.  J. 
Peck,  P.  M. 
Pellette,  E.  F. 
Petree,  Martha 
Phinney,  C.  H. 
Piatt,  R. 
Proctor,  E.  R. 
Ray,  T.  L. 
Reid,  C.  C. 
Riley,  G.  W. 
Robb,  L.  G. 
Scammon,  E. 
Sisson,  Ernest 
Slosson,  Jane 
Smith,  A.  M. 
Smith,  Grace  L. 
Smith,  F.  H. 
Smith,  R.  K. 
Snow,  G.  H. 
Starbuck,  Calla  E. 
Still,  A.  T. 
Still,  Ella  D. 
Still,  Geo.  A. 
Tasker,  D.  L. 
Taylor,  S.  L. 
Teall,  C.  C. 
Tice,  E.  A. 
Treat,  Clara  L. 
Tucker,  A.   R. 
Tucker,  E.  E. 
Vastine,  H.  M. 
Weaver,  M.  J. 
Webster,  G.  V. 
Weeks,  R.  F. 
Wendell,  Canada 
Whiting,  C.  A. 
Whiting,  Lillian  M. 
Willard,  Asa 
Willard,  E.  S. 
Williams,  C.  A. 
Williams,  Ralph 
Woodall,  P.  H. 
York,  Effie  E. 
Zealey,  A.  H. 


12 


PART  I 
DISEASES  OF  THE  DIGESTIVE  SYSTEM 


GENERAL  DISCUSSION 

The  adequate  treatment  of  diseases  of  the  digestive  system 
rests  upon  a  knowledge  of  the  function,  circulation  and  innerva- 
tion of  this  long  tube  which  traverses  the  body. 

For  convenience,  this  alimentary  tube  may  be  divided  into 
three  chief  groups  which  differ  from  each  other  in  many  respects. 
First,  the  mouth  with  the  salivary  glands,  the  pharynx,  and  the 
esophagus;  Second,  the  stomach,  small  intestine,  liver  and  pan- 
creas; Third,  the  colon,  sigmoid  and  rectum. 

In  the  first  group  we  have  the  mouth,  salivary  glands,  pharynx 
and  esophagus.  All  of  these  tissues  are  well  supplied  with  arte- 
rial blood  and  have  very  free  venous  and  lymph  drainage.  The 
blood  vessels  are  innervated  by  vasomotor  nerves  from  the  cranial 
and  upper  cervical  sympathetic  ganglia,  which  receive  their  stimu- 
lation from  the  centers  in  the  medulla,  chiefly  by  way  of  the 
seventh  cranial  nerves;  and  from  the  first  to  the  fourth  thoracic 
spinal  segments  by  way  of  the  gray  rami  and  the  sympathetic 
chain.  These  nerve  centers  are  somewhat  affected  by  impulses 
from  the  emotional  centers,  but  their  chief  control  is  through  sen- 
sory nerves  of  the  same  and  neighboring  segments.  Bony  lesions 
of  the  mandible,  hyoid,  occiput,  atlas,  axis,  other  cervical  vertebrae, 
the  first  and  second  ribs  and  the  clavicle  are  ef^cient  causes  for 
disturbed  function  of  the  nerve  centers  which  control  the  secretion, 
circulation  and  nutrition  of  the  mouth,  tonsils,  salivary  glands  and 
pharynx  and  esophagus.  Such  lesions  lower  resistance  to  infec- 
tion, increase  and  perpetuate  the  effects  of  traumatic  or  toxic  influ- 
ences and  hinder  recovery  in  practically  all  forms  of  diseases  of 
the  organs  mentioned.  The  food  remains  in  the  mouth,  pharynx 
and  esophagus  so  short  a  time  that  only  very  marked  or  constant 
dietetic  errors  cause  injury. 

In  the  second  group — the  stomach  and  small  intestine,  the  liver 
and  the  pancreas — is  found  a  set  of  organs  which  also  has  a 
double  innervation.  The  vagus  carries  motor  and  secretory 
impulses  to  these  organs  by  way  of  the  solar  plexus.  Probably 
some  vasomotor  fibers  derived  from  the  lateral  chain  of  sym- 
pathetic ganglia  may  be  carried  by  way  of  the  vagus.  Certainly 
the  splanchnic  nerves  which  are  derived  from  the  sixth  to  the 
twelfth  thoracic  segments  carry  nerve  fibers  which  are  distributed 
in  a  somewhat  segmental  manner  to  this  part  of  the  digestive  tube. 

13 


14  -     DIGESTIVE  SYSTEM      ' 

All  of  these  organs  receive  sensory  innervation,  both  by  the 
splanchnic  and  the  vagus  nerves.  Bony  lesions  of  the  occiput, 
atlas  and  axis  are  responsible  for  certain  functional  gastric  dis- 
turbances, and  lesions  of  the  spinal  column  and  the  ribs,  especially 
from  the  fifth  to  the  tenth  thoracic,  result  in  circulatory,  secretory 
and  trophic  disturbances  of  the  stomach,  small  intestine,  liver  and 
pancreas. 

Variations  from  the  normal  quality  and  quantity  of  food  may 
have  marked  effects  upon  these  organs.  So  long  does  the  food 
stay  in  the  stomach  and  in  the  small  intestine  and  so  profoundly  is 
the  chemistry  of  the  food  modified  by  the  digestive  secretions  of 
this  part  of  the  alimentary  tract  and  by  bacterial  action  that  we 
must  recognize  very  clearly  the  influence  of  dietetic  errors  in  the 
etiology  of  diseases  affecting  these  organs. 

The  fact  that  gastric  activity  is  speedily  and  profoundly  modi- 
fied by  emotional  disturbances  is  demonstrated  by  such  frequent 
experiences  that  probably  no  one  has  failed  to  appreciate  it  either 
in  his  ow^n  or  his  neighbor's  life. '  It  is  also  true  that  sudden  pain, 
as  for  example  from  sciatica  or  toothache,  affects  the  digestive 
activity. 

When  bony  lesions  of  the  occiput,  upper  cervical  and  mid- 
thoracic  spinal  column,  the  ribs  or  the  mandible  are  present,  or 
when  there  is  any  lack  of  normal  mobility  of  the  articular  surfaces 
in  these  areas,  the  gastro-enteric  centers  either  fail  to  receive 
their  normal  stimulation  or  they  are  acted  upon  by  irritating 
streams  of  sensory  impulses.  The  normal  nerve  control  of  the 
stomach  is  thus  interfered  with  in  much  the  same  way  as  might 
occur  if  constant  emotional  disturbances  were  present.  Under 
such  circumstances  even  normal  food  may  provoke  an  attack  of 
gastritis  or  enteritis  while  dietetic  errors,  for  which  the  normal  pro- 
tective mechanisms  of  the  body  should  be  entirely  adequate,  may 
bring  about  digestive  disturbances  out  of  all  proportion  to  the 
apparently  trivial  cause. 

Since  many  of  the  products  of  digestion  are  carried  through 
the  liver  this  organ  also  is  subject  to  the  adverse  influences  of 
improperly  chosen  or  imperfectly  digested  foods.  It  is  not  yet 
shown  whether  the  quality  of  the  food  stuffs  exercises  any  abnormal 
influence  over  the  pancreas  or  not. 

The  third  group,  the  colon,  sigmoid  and  rectum,  has  its  chief 
innervation  from  the  lumbar  and  sacral  nerves.  These  nerve  cen- 
ters may  be  profoundly  affected  by  sensory  nerve  impulses  reach- 
ing them  from  the  articular  surfaces  of  the  lumbar  vertebrae,  the 
sacrum,  the  innominates  and  the  hip  joints  as  well  as  from  the 
abdominal  viscera.  The  arterial  supply  of  the  lower  part  of  the 
alimentary  tract  is  plentiful  and  the  anastomosis  is  very  free.  The 
veins  are  large  with  free  anastomoses  but  the  return  flow  of  venous 
blood  is  liable  to  be  impeded  by  slight  or  profound  hepatic  dis- 


GENERAL  DISCUSSION  U 

turbances  and  this  column  of  blood  is  always  subject  to  the  adverse 
influence  of  gravitation.  The  structural  circulatory  relations  pre- 
dispose to  the  formation  of  hemorrhoids  and  diminished  resistance 
of  the  rectum  and  its  neighboring  tissues. 

During  this  part  of  its  passage  through  the  alimentary  canal 
the  food  stuff  undergoes  little  change.  The  walls  are  not  pro- 
foundly affected  by  abnormalities  in  diet  except  as  these  result  in 
too  great  or  too  little  quantities  of  waste  material,  or  as  the 
strength  of  the  body  may  be  influenced  from  the  standpoint  of 
nutrition.  The  colon  itself  is  subject  to  pressure  from  too  long 
retention  of  the  fecal  mass  and  certain  structural  perversions,  lead- 
ing to  its  ptosis  and  to  the  effects  of  much  ill-judged  treatment 
for  constipation. 

These  considerations  lead  to  the  view  that  the  more  common 
digestive  diseases  are  always  complex  in  etiology;  that  in  dealing 
with  any  of  these  cases  we  have  to  take  into  consideration  not 
only  the  habits  of  eating,  the  quality  and  quantity  of  food,  the 
manner  in  which  the  food  is  prepared  and  served  and  eaten,  the 
habitual  emotional  state  of  the  patient  at  meal  time,  but  also  the 
structural  relationships  of  the  entire  body. 

"Formerly  in  many  confusing  conditions  of  the  gastrointestinal  tract,  diag- 
nosis could  only  be  made  by  the  aid  of  an  explorative  laparotomy.  The  need 
for  many  of  these  has  been  removed  by  modern  Roentgenology. 

"The  information  gained  by  careful  study  of  the  gastrointestinal  tract  when 
containing  the  'bismuth  meal'  or  enema,  or  under  air  or  gas  inflation,  can 
often  be  secured  in  no  other  way.  A  positive  diagnosis  can  be  made  of  stric- 
tures or  diverticulae,  the  tone,  motility  and  patency  throughout  the  tract.  The 
fluoroscope  shows  position,  size,  shape,  capacity,  motility  and  functioning 
of  the  stomach  and  its  gateways,  as  well  as  the  presence  or  absence  of 
ulcers,  with  their  resulting  constrictions  or  carcinoma  with  its  typical  infil- 
tration. Definite  location  of  pathology  can  usually  be  obtained  throughout 
the  tract.  The  amount  and  character  of  the  waves  of  peristalsis  can  be  seen 
and  studied  as  carefully  as  can  the  pupillary  reflex  or  the  radial  pulse.  Serial 
plates  enable  one  to  know  the  length  of  time  that  is  required  for  different 
portions  of  the  tract  to  empty  themselves.  Thus  stasis  from  any  cause,  as 
adhesions,  deformity  of  structure,  lack  of  muscular  tone,  or  ileus  is  located 
and  its  cause  often  disclosed.  The  'geography'  of  the  colon  is  of  much 
importance  in  many  cases ;  its  course,  diameter,  permeability  and  motility 
are  definitely  shown  by  the  X-Ray.  Distention  of  the  sigmoid  flexure  is  often 
demonstrated,  giving  a  cause  for  remote  symptoms  due  to  pressure  irritation 
or  to  toxin  absorption. 

"Thus  the  X-Ray  is  one  of  the  most  valuable  and  complete  aids  to  diag- 
nosis of  conditions  of  the  gastrointestinal  tract  to  which  the  modern  physician 
has  recourse." — E.  R.  Hoslans  and  M.  h-  Burns. 


CHAPTER  I 

DISEASES  OF  THE  MOUTH  AND  THE  SALIVARY 

GLANDS 

STOMATITIS 

This  is  an  inflammation  of  the  mouth  and  its  associated  struc- 
tures, due  to  irritants,  either  mechanical,  thermal  or  chemical, 
infection  by  fungi  or  bacteria,  and  accompanied  by  feverishness, 
discomfort  or  pain  and  other  symptoms  dependent  upon  the  struc- 
tural changes  and  the  variety.  In  all  forms  reflex  muscular  con- 
tractions and  hypersensitive  areas  are  found  around  the  angle  of 
the  jaw  and  the  upper  cervical  region,  both  anterior  and  posterior. 

Lesions  of  the  hyoid,  mandible,  and  cervical  vertebrae  are  pre- 
disposing factors  in  the  infections,  or  may  be  secondary.  These 
lesions,  as  well  as  the  reflex  muscular  contractions  mentioned,  may 
tend  to  delay  recovery  from  the  effects  of  either  mechanical,  ther- 
mal, chemical  or  infectious  irritants. 


ACUTE  CATARRHAL  STOMATITIS 

(Simple  stomatitis;  erythematous  stomatitis;  catarrh  of  the  mouth) 

This  is  due  to  irritants  of  any  kind.  In  poorly  nourished  chil- 
dren it  is  associated  with  dentition  and  gastrointestinal  disorders; 
in  adults  with  the  abuse  of  tobacco  or  it  may  be  caused  by  chemical 
and  thermal  irritants.  It  occurs  constantly  with  indigestion  and 
the  specific  fevers. 

Diagnosis.  It  is  marked  by  superficial  redness,  heat  and  swell- 
ing, dryness  followed  by  increased  secretion,  and  by  swelling  of 
the  papillae  of  the  tongue. 

Feverishness  is  most  noticeable  in  children.     Discomfort  par- 
ticularly in  mastication  may  be  very  annoying. 

Treatment.  Irritating  factors  must  be  removed.  Food  and 
drinks  must  be  lukewarm  or  cool.  In  severe  cases  only  liquid 
food  can  be  given,  and  this  should  be  taken  through  a  bent  glass 
tube  or  a  straw.  The  mouth  must  be  washed  at  frequent  intervals 
with  distilled  or  boiled  water,  or  with  mild  solutions  of  boric  acid, 
salt,  etc. — anything  which  is  non-irritating  and  gives  a  sensation 
of  comfort  and  cleanliness. 

Reflex  muscular  contractions  should  be  relieved.  Bony  lesions 
especially  of  the  hyoid,  mandible,  clavicle,  and  th-:.  cervical  ver- 

16 


APHTHOUS  STOMATITIS  17 

tebrse  are  to  be  corrected  if  possible  without  causing  too  great 
discomfort.  If  the  corrective  measures  are  very  painful,  it  is  better 
to  delay  that  work  until  the  acute  stage  has  passed. 

When  the  stomatitis  is  part  of  an  acute  infectious  disease,  the 
treatment  for  that  disease  is  part  of  the  treatment  for  the  stom- 
atitis. When  mal-nutrition  is  present,  the  stomatitis  usually  per- 
sists or  recurs  until  the  general  health  is  improved.  In  ordinary 
cases,  the  duration  is  about  a  week. 

APHTHOUS  STOMATITIS 

(Follicular  or  vesicular  stomatitis;  croupous  stomatitis;  "canker"  sore  mouth) 

This  is  due  to  various  causes — in  children,  to  poor  nourishment 
and  uncleanliness,  indigestion  and  fever;  in  women,  sometimes  to 
menstrual  periods,  pregnancy  and  the  puerperium,  and  in  men 
to  protracted  sprees,  and  to  general  ill-health. 

Diagnosis.  The  appearance  is  characteristic.  To  the  features 
of  the  catarrhal  form  is  added  the  formation  of  small,  grayish  or 
yellowish  white  spots,  either  simple  or  in  clusters.  At  first  ves- 
icular, these  later  become  ulcers  of  a  dull  opaque  appearance 
bounded  by  a  bright  red  hyperemic  zone.  They  are  found  upon 
the  lips,  the  tongue  or  upon  the  cheeks. 

There  is  soreness  of  the  mouth,  increased  secretion,  heavy 
breath,  and  the  symptoms  of  the  associated  disease.  These  ulcers 
heal  rapidly  when  the  constitutional  condition  is  improved. 

Treatment.  The  treatment  of  catarrhal  stomatitis  should  be 
given,  and  to  this  added  careful  washing  of  the  ulcers,  preferably 
with  mild  boric  acid  solution.  The  gastric  condition  should  be 
investigated,  and  appropriate  treatment  initiated  for  whatever  gas- 
tric disorders  may  be  found. 

Prognosis.  The  ulcers  disappear  with  remarkable  speed  when 
the  cause  of  the  stomatitis  is  removed ;  but  they  persist  and  recur 
obstinately  unless  the  source  of  the  trouble  is  removed. 

MEMBRANOUS  STOMATITIS 

(Croupous  stomatitis) 

This  is  a  disease  which  resembles  that  just  mentioned,  except 
that  instead  of  the  formation  of  small  ulcers,  there  is  a  dense  gray- 
ish membrane  over  the  mucous  surface.  It  is  sometimes  diphtheritic 
(see  diphtheria)  and  sometimes  results  from  streptococcic,  gonor- 
rhoeal,  or  other  infection.  It  may  be  present  in  the  new-born, 
from  gonorrhoeal  infection;  or  from  syphilis.  The  treatment  is 
that  of  the  infectious  agent,  plus  that  of  aphthous  stomatitis.  The 
prognosis  is  rarely  good. 


18  THE  MOUTH 

ULCERATIVE   STOMATITIS 

(Diphtheritic  or  fetid  stomatitis;  putrid  sore  mouth;  gingivitis  ulcerosa) 
This  is  an  acute  affection,  often  epidemic. 

Etiology.  The  disease  results  from  defective  sanitary  condi- 
tions; poor  nourishment;  from  exhausting  diseases  as  diabetes, 
scurvy;  poisoning  from  mercury,  lead,  phosphorus,  or  copper. 

Diagnosis.  The  first  changes  appear  in  the  gums  around  the 
roots  of  the  teeth.  The  tissues  are  at  first  red,  swollen,  and 
edematous  with  warty  projections,  and  the  inflammation  spread- 
ing along  the  line  of  the  g^ms.  Later,  the  parts  become  pale, 
spongy  and  friable,  bleeding  at  the  slightest  touch,  and  eventually 
becoming  necrotic.  The  ulceration  may  extend  to  the  lips  and 
cheeks,  and  may  penetrate  deeply  to  the  bones.  The  teeth  may 
fall  out.  The  saliva  is  increased  in  amount  and  is  acid  in  reaction ; 
the  breath  is  foul;  mastication  is  difficult;  the  submaxillary  glands 
are  enlarged.  The  constitutional  symptoms  may  be  severe  in, 
children,  occasionally  resulting  in  death  in  debilitated  subjects. 

Treatment.  This  must  be  energetip.  The  ulcers  must  be 
washed  with  mild  antiseptics  frequently ;  a  mildly  alkaline  solution 
is  best.  The  food  must  be  liquid,  and  must  be  taken  through  a 
glass  tube,  which  must  be  kept  well  sterilized.  The  general  con- 
dition of  the  patient  must  determine  the  quality  of  the  food;  in 
cases  with  symptoms  of  scurvy  the  juices  of  fresh  vegetables  must 
be  given;  in  patients  who  are  starved,  broths,  digested  foods,  etc., 
may  be  freely  given. 

Energetic  stimulating  treatment  to  the  mid-thoracic  region  is 
indicated.  The  ribs  should  be  raised  carefully,  avoiding  too  great 
tension  upon  the  viscera.  The  gastro-intestinal  symptoms  must 
be  met  as  they  appear.     (See  diarrhoeas  of  children.) 

Prognosis.  If  the  tissue  destruction  is  not  marked,  a  good  out- 
look follows  proper  treatment.  In  later  cases,  loss  of  the  teeth, 
injury  to  the  soft  parts,  and  sometimes  necrosis  of  the  mandible 
may  follow.  The  constitutional  disease  gives  the  more  grave 
prognosis. 

PARASITIC  STOMATITIS 

(Thrush;  sprue;  white  mouth;  soor;  muguet;  myocotic  stomatitis) 

Thrush  is  due  to  the  saccharomyces  or  oidium  albicans.  Pre- 
disposing causes  are  bottle-fed  infants,  debilitated  adults,  use  of 
starchy  and  milk  foods  with  imperfect  cleansing  of  the  mouth, 
catarrhal  stomatitis. 

Diagnosis.  The  disease  first  appears  upon  the  l^ngue  and  inner 
^ides  of  the  cheeks  as  a  diffuse  reddening  of  the  mucosa  and  the 


MERCURIAL  STOMATITIS  19 

formation  of  a  glistening,  slimy,  somewhat  adhesive  exudate  of 
grayish  appearance.  Small  whitish  dots  next  appear  and  stand  out 
prominently  upon  the  red  hyperemia  background.  These  patches 
tend  to  coalesce  to  form  a  membrane  which  when  removed  leaves 
a  greatly  reddened  and  often  eroded  mucosa,  the  membrane  quickly 
reappearing.  The  growth  of  the  fungus  begins  in  the  epithelial 
layer  and  extends  to  the  deeper  structures.  Severe  cases  may 
iaclude  the  palate,  lips,  pharynx,  or  esophagus,  rarely  the  internal 
organs. 

The  mouth  is  usually  dry,  tender  and  painful.  There  is  debil- 
ity and  gastric  disturbance.  The  membrane  can  be  readily  removed, 
usually  leaving  an  intact  mucosa  beneath. 

The  fungus  is  easily  recognized  by  microscopic  examination  of 
a  scraping. 

Treatment.  Food  should  be  stopped  for  a  few  feedings,  and 
plenty  of  water  given.  The  mouth  should  be  washed  with  cotton 
or  gauze,  in  warm  alkaline  solutions.  Cleanliness  after  recovery 
is  important.  The  reflex  muscular  contractions  should  be  relieved, 
even  in  very  young  babies.  Rarely,  vertebral  lesions  are  found; 
these  must  be  corrected. 

Prognosis.    Recovery  is  to  be  expected  within  a  few  days. 

MERCURIAL  STOMATITIS 

(Ptyalism) 

This  is  due  to  the  use  of  mercurial  preparations  medicinally  or 
to  handling  of  mercury  as  in  certain  occupations.  The  gums  are 
swollen,  red  and  sore,  the  salivary  glands  are  enlarged  and  pain- 
ful with  greatly  increased  secretion. 

There  is  a  metallic  taste  in  the  mouth,  tenderness  upon  shut- 
ting the  teeth  and  fetid  breath,  mastication  is  difficult,  the  tongue 
is  swollen,  tender  to  the  touch  and  covered  with  a  heavy,  creamy 
coating.  If  the  case  is  severe,  the  teeth  are  lost,  ulcers  form,  and 
rarely  necrosis  of  the  jaw  occurs. 

The  duration  is  from  two  to  four  weeks. 

Treatment.  The  first  consideration  is  to  stop  the  mercurial 
poisoning.  The  occupation  should  be  changed  if  necessary.  Out- 
of-door  life  is  important.  As  rapid  elimination  of  the  poison  as  is 
possible  should  be  secured  by  promoting  activity  of  all  excretory 
organs  and  assisting  this  by  hot  or  Turkish  baths.  The  stom- 
atitis is  only  a  sign  of  the  general  poisoning. 

Prognosis.  If  the  use  of  mercury  is  stopped,  and  the  tissue 
destruction  is  not  too  great,  recovery  is  complete.  In  more  serious 
cases,  the  teeth  are  loosened,  and  may  fall  out. 


20  THB  MOUTH 

GANGRENOUS  STOMATITIS 

(Noma;  cancrum  oris;  cancer  aquaticus  or  water  cancer) 

Etiology.  It  is  usually  due  to  very  insanitary  conditions  but 
may  occur  during  convalescence  from  the  acute  fevers,  measles, 
scarlatina,  typhoid  and  pneumonia,  especially  in  children  between 
two  and  twelve  years. 

Diagnosis.  It  begins  with  the  formation  of  a  livid,  swollen 
patch,  usually  unilateral,  in  the  buccal  mucosa,  near  the  angle  of 
the  mouth  or  in  the  gums.  Small  blisters  form,  the  tissues  present 
a  grayish-yellow  inflammatory  infiltration  that  quickly  becomes 
gangrenous,  spreads  rapidly  until  the  whole  thickness  of  the  cheek 
is  converted  into  a  reddish-black  necrotic  mass  which  may  pene- 
trate so  as  to  involve  the  bones  of  the  nose  and  jaw.  The  struc- 
tures in  the  neighborhood  are  infiltrated  and  edematous.  Septic 
infection  of  the  whole  system  usually  sets  in  with  a  fatal  result. 

The  constitutional  symptoms  are  great,  fever  irregular  (103° 
to  104°  F.)  rapid  pulse,  delirium,  diarrhea,  and  prostration.  The 
breath  has  a  peculiar  penetrating  and  intolerably  offensive  odor. 
Aspiration  (septic)  pneumonia,  gangrene  of  the  female  genitalia, 
and  colitis  are  common  complications. 

Treatment.  The  disease  does  not  occur  in  children  who  have 
proper  care.  When  it  is  found,  the  only  treatment  is  symptomatic 
and  constitutional,  according  to  conditions  found  in  each  case. 
Antiseptic  washes  are  to  be  used. 

Prognosis.  The  duration  is  from  seven  to  fourteen  days,  when 
death  is  to  be  expected.  In  the  rare  cases  of  recovery  consider- 
able deformity  is  unavoidable. 

CHRONIC  STOMATITIS 

Is  caused  by  chronic  irritation  due  to  smoking  or  by  syphilis. 

Diagnosis.  The  mucous  membrance  is  infiltrated,  lymph-fol- 
licles are  enlarged,  the  epithelium  is  thickened  and  keratinized. 
Grayish  or  bluish-white  flattened  plaques  arc  seen  on  the  tongue 
and  inner  sides  of  the  lips  and  cheeks.  This  condition  may  afford 
a  starting  point  for  carcinoma.  The  disease  causes  few  symptoms, 
mainly  irritative.  The  diagnosis  rests  upon  the  appearance  of  the 
mouth  and  the  history  of  irritative  factors. 

Treatment.  The  irritating  factors  must  be  absolutely  removed. 
The  food  must  be  non-irritating,  smooth  or  liquid  in  consistency. 
Muscular  contractions,  especially  around  the  angles  of  the  jaws, 
and  under  the  tongue  must  be  relieved.  Bony  lesions  must  be 
corrected  wherever  found.  Upper  thoracic  lesion  are  almost 
invariable.     Clavicles  and  upper  ribs  are  often  at  fault. 


THE  TONGUE  21 

Prognosis.  With  persistent  treatment,  recovery  may  be  almost 
or  quite  complete.  More  often  hardened  areas  are  left.  The  dan- 
ger of  beginning  carcinoma  must  be  recognized,  as  in  leucoplakia 
buccalis.  (q.v.) 

OTHER  DISEASES  OF  THE  MOUTH 

The  mouth  is  subject  to  various  congenital  deformities  as  tongue-tie,  hare- 
lip, and  cleft-palate,  all  of  which  are  relieved  to  a  greater  or  less  extent  by 
surgical  measures. 

The  structures  of  the  mouth  are  subject  to  diseases  which  may  be  a  part 
of  the  general  process  or  remain  localized. 

Syphilis,  tuberculosis,  actinomycosis,  leprosy  and  glanders  of  the  mouth 
are  described  in  connection  with  the  general  discussion  of  these  diseases. 

TUMORS.  The  most  common  malignant  tumor  is  the  epithelioma.  "Smok- 
er's cancer"  may  be  mentioned ;  also  the  cancer  due  to  use  of  the  betel  nut. 

Ranula  are  small  retention  cysts  of  the  mucous  glands. 

The  most  common  of  the  benign  tumors  are  fibroids  and  papillae. 

The  treatment  of  all  these  is  surgical;  and  the  value  of  surgery  depends 
upon  an  early  diagnosis. 

RIGA'S  DISEASE.  This  is  a  strange  local  ulcer  appearing  near  the 
frenum  of  the  tongue.  It  is  endemic  and  epidemic  "m  Italy,  but  not  seen  in 
this  country  except  among  new  arrivals.    It  is  most  frequent  in  teething  infants. 

THE  TONGUE 

Since  the  nerves  which  control  the  tongue  include  vasomotor, 
secretory,  sensory,  and  somatic  motor  elements,  and  since  these 
have  extremely  intricate  central  relationships,  the  tongue  is  one  of 
the  important  diagnostic  structures  of  the  body.  Its  appearance, 
control,  and  sensations  are  all  important  in  diagnosis,  under  cer- 
tain circumstances. 

Pain  from  other  organs  is  rarely  referred  to  the  tongue,  but  it 
is  not  at  all  rare  for  diseased  conditions  of  the  anterior  part  of  the 
tongue  to  be  associated  with  pain  in  the  chin.  Injury  to  the  lateral 
area  may  cause  pain  under  the  jaw  or  around  the  hyoid  bone,  caus- 
ing the  patient  to  complain  of  a  "stifif  neck."  When  the  tongue 
lesion  is  placed  on  the  posterior  area  the  pain  may  be  in  the  sub- 
occipital region,  and  intense  muscular  contractions  in  that  area 
may  mislead  in  the  search  for  a  diagnosis. 

FETOR  ORIS.  This  is  a  common  affection  resulting  from  digestive 
troubles,  local  mouth  conditions,  all  forms  of  stomatitis  and  pyorrhea  alveolaris, 
tonsillar  diseases,  caries  of  the  teeth,  respiratory  diseases  from  the  nose  to 
lungs,  and  certain  constitutional  diseases. 

Treatment.  The  imderlying  conditions  must  be  found  before  a  permanent 
relief  can  be  gained,  and  these  carefully  treated  by  correction  of  structural 
derangements,  correction  of  diet  and  general  hygiene,  and  insistence  upon  a 
strict  regime  of  oral  antisepsis. 

COATINGS  OF  THE  TONGUE.  The  appearance  of  the  tongue  is 
useful  in  diagnosis.     The   fur  or   coating  is   due  to  accumulated   epithelium, 


22  THB  MOUTH 

fungi,  and  food  particles.  It  is  uniformly  seen  in  febrile  diseases,  gastro-intes- 
tinal  disorders,  naso-pharyngeal  affections,  and  is  not  unusual  in  apparently 
good  health. 

Unilateral  furring  results  from  some  disturbance  of  the  second  and  third 
branches  of  the  fifth  nerve. 

Circumscribed .  furring  usually  points  to  some  local  trouble. 

White  coating  of  fungi,  bacteria,  and  desquamated  epithelium  arises  from 
nerve  irritation ;  disturbed  circulation  and  innervation  prevent  normal  forma- 
tion and  removal  of  the  epithelium,  and  opportunity  is  thus  afforded  for  the 
growth  of  ftingi. 

A  flabby,  swollen,  indented  tongue,  covered  with  an  even  yellow,  pasty  fur 
is  seen  in  catarrhal  gastritis  or  gastro-duodenitis  and  in  heavy  smokers  and 
drinkers.     It  occurs  also  in  continued   fever  of  some  length. 

A  dry,  brown,  fissured  tongue  stained  with  bile  is  found  in  the  low  fevers, 
such  as  typhoid  and  dysentery. 

A  black  tongue  is  observed  in  malignant  fevers. 

A  bluish-black  tongue  is  occasionally  seen  in  Addison's  disease. 

A  red,  beefy  tongue  is  seen  in  diabetes  and  wasting  diseases. 

The  strawberry  tongue,  white  with  red  points,  is  especially  characteristic 
of  scarlet  fever. 

A  trembling  tongue  is  seen  in  paresis  and  similar  nervous  diseases  and  in 
alcoholism  and  asthenic  fevers. 

GLOSSITIS 

Glossitis  is  an  acute  or  chronic  inflammation  of  the  parenchyma 
of  the  tongue,  usually  due  to  injury,  and  characterized  by  great 
swelling,  redness,  and  pain  with  difficult  functioning. 

It  is  due  to  direct  injury  as  biting  the  tongue,  erosion  by  the 
teeth,  contact  with  boiling  liquids  or  other  irritants,  corrosive 
poisons,  the  stings  of  insects,  and  other  forms  of  trauma. 

Subluxations  of  the  atlas,  axis,  and  other  cervical  vertebrae,  the 
first  rib,  the  inferior  maxillary  or  the  hyoid  bone,  and  muscular 
lesions  of  the  cervical  and  upper  costal  muscles  affect  the  circula- 
tion through  the  tongue,  and  in  this  way  slight  injuries  cause  more 
serious  inflammations ;  recovery  is  delayed  by  the  same  lesions. 

The  superficial  form  is  catarrhal  and  results  in  denudation  of 
the  surface  and  is  constantly  present  in  febrile  conditions. 

The  deep  form  consists  of  hyperemia,  infiltration  with  leuco- 
cytes with  perhaps  atrophy  and  degeneration  of  the  muscle  fibers 
following,  or  abscesses  may  arise  from  pyogenic  infection. 

Diagnosis.  The  tongue  is  swollen,  painful  and  hardened. 
Increased  flow  of  saliva;  difficult  mastication,  deglutition  and 
speech ;  fever  with  its  constitutional  disturbances,  and  suppuration 
may  occur.  Reflex  contractions  of  the  muscles  of  mastication  and 
deglutition  are  usually  present.  Hypersensitive  areas  are  found 
around  the  mandibular  articulation  and  in  the  neighborhood  of 
the  third  cervical  vertebrae. 

Treatment.  Relaxation  of  all  the  cervical  muscles  especially 
the  deep  ones  and  those  at  the  angle  of  the  jav.,  correction  of 
any  deviations  found  either  in  the  vertebrae  or  the  ribs  or  the 


LEUCOPLAKIA  BUCCALIS  23 

hyoid  are  indicated.  If  pus  has  formed,  incision  is  necessary. 
Heat  applied  at  the  angle  of  the  jaw  may  give  relief  during  the 
intervals  of  treatment.  Tracheotomy  may  be  necessary  to  prevent 
suffocation. 

Prognosis.  With  early  treatment  recovery  is  to  be  expected. 
Convalescence  is  slow.  The  purulent  form  is  serious.  Gangrene 
is  more  frequent  than  spontaneous  resolution.  Death  may  occur 
from  suffocation. 

GEOGRAPHICAL  TONGUE 

(Eczema  of  the  tongue) 

This  is  an  inflammation  of  the  tongue  with  desquamation  of 
the  superficial  epithelium.  The  central  portions  of  the  round 
patches  heal,  which  cause  the  tongue  to  resemble  a  map.  Itching 
and  heat  may  cause  much  annoyance.  It  is  of  unknown  etiology; 
occurs  in  infants  and  children,  not  infrequently  in  adults,  and  is 
liable  to  relapse. 

Treatment.  The  treatment  is  based  upon  the  conditions  as 
found  on  examination.  Lesions  responsible  for  the  disturbed  cir- 
culation include  those  already  named  in  connection  with  glossitis. 
These  are  to  be  corrected  when  present.  The  condition  of  the 
digestive  tract  as  a  whole  is  to  be  investigated,  and  appropriate 
treatment  initiated  for  whatever  variations  from  the  normal  are 
found. 

The  food  must  be  nonirritating  and  liquid.  Strict  milk  diet 
has  been  useful  in  some  instances.  An  examination  of  the  blood 
will  often  give  useful  information  concerning  the  requirements 
of  the  body. 

Prognosis.  Relapse  is  frequent.  Recovery  from  each  attack 
is  to  be  expected,  under  proper  care,  but  may  be  considerably 
delayed. 

LEUCOPLAKIA  BUCCALIS 

(Ichthyosis  Ungualis;  buccal  psoriasis;  smoker's  tongue;  leuco-keratosis 

mucosae  oris) 

This  is  a  most  obstinate  chronic  inflammation  of  the  tongue, 
probably  due  to  syphilis,  with  thickening  of  the  squamous  epi- 
thelium and  the  formation  of  firm,  often  white  or  pearly  glistening 
plaques,  occurring  most  commonly  in  heavy  smokers.  The  lingual 
papillae  may  be  hypertrophied.  It  occurs  in  three  ^varieties :  (1) 
small,  white  slightly  raised,  even  papillomatous  spots  (lingual 
corns)  ;  (2)  a  diffuse,  thin,  bluish-white  or  opaque  white  coating 
of  the  tongue,  which  is  patchy  and  is  most  often  seen  upon  the 
dorsum  and  sides;  (3)  diffuse  oral  leucoplakia  involving  the  whole 
oral  cavity  and  its  mucosa.  The  edges  of  the  patches  are  favorite 
localities  for  beginning  cancer  of  the  mouth. 


24  THU  MOUTH 

Treatment.  Surgery  is  advised  when  the  patches  are  localized. 
Smoking  should  be  discontinued.  All  irritating  foods  and  drinks 
should  be  avoided.  The  removal  of  whatever  lesions  may  be 
found  interfering  with  the  circulation  may  be  tried. 

Prognosis.  The  hardened  areas  can  hardly  be  expected  to  dis- 
appear, except  after  long  cessation  of  the  irritating  factors. 
Patients  who  have  subjected  the  tongue  to  such  treatment  as  is 
necessary  to  cause  the  disease,  are  hardly  apt  to  endure  the  restric- 
tion necessary  for  recovery.  The  edges  of  the  plaques  are  a  con- 
stant irritant  to  the  neighboring  epithelium,  and  cancers  often 
begin  in  these  tissues.  Patients  in  whose  families  cancer  has 
appeared  should  be  warned  of  this  danger,  and  taught  to  avoid 
further  irritation  of  the  tongue. 

DISEASES  OF  THE  LIPS 

The  lips  are  the  location  of  a  few. primary  affections  and  a 
number  of  secondary  ones.  They  are  often  involved  in  ordinary 
cutaneous  diseases  such  as  lupus,  eczema,  tenea,  circinata,  psoriasis, 
urticaria,  tuberculosis  rarely,  and  occasionally  syphilis.  The  pos- 
sibility of  chancre  of  the  lips  must  not  be  forgotten. 

Acute  Catarrhal  Cheilitis.  The  commonest  affection  of  the 
lips  is  that  which  is  called  "chapping."  This  is  a  mild  catarrhal 
inflammation,  usually  caused  by  the  action  of  very  dry  or  cold 
air  upon  the  lips.  It  may  be  very  severe  in  those  who  are  exposed 
to  the  air  from  the  desert  or  winter  in  a  rigorous  climate.  The 
thickened  epithelium  is  detached  in  shreds  leaving  the  upper  layers 
painful,  bleeding,  and  the  seat  of  subsequent  inflammations.  Pick- 
ing at  these  shreds  of  skin  makes  the  condition  much  worse.  The 
fissures  may  be  so  deep  as  to  cause  great  pain  and  considerable 
disfigurement. 

The  tendency  toward  chapping  of  the  lips  is  noted  in  persons 
whose  general  nutrition  is  lessened  in  any  way  and  also  in  those 
who  suffer  from  lesions  of  the  first  and  second  thoracic  vertebra. 

The  treatment  of  chapped  lips  includes  their  protection  with 
some  nonirritating  oily  material.  Warm  applications  may  be 
gratefully  received.  Patients  who  have  a  lendency  to  chapped 
lips  upon  slight  exposure  should  receive  examination  into  the 
predisposing  factors  present,  and  the  removal  of  these  if  possible. 

Herpes  Labialis  (Herpes  facialis)  is  a  disease  of  the  lips  present 
in  fevers,  especially  in  those  included  as  "bad  colds."  The  small 
vesicles  which  first  appear  may  become  infected  with  pyogenic 
bacteria,  and  develop  into  quite  large  and  very  painful  ulcers. 
They  may  occur  frequently,  with  no  recognizable  cause,  in  persons 
who  are  poorly  nourished  or  exposed  to  improper  climatic  condi- 
tions.    The  treatment  consists  in  protection  with  any  mild  and 


THE  TEETH  25 

pleasant  oily  or  gelatinous  material,  the  removal  of  the  systemic 
conditions,  and  such  other  corrective  measures  as  may  be  found  in- 
dicated on  examination. 

PERLECHE  is  a  serious  disease  of  the  lips,  not  frequently  present  in 
this  country.  It  is  present  usually  in  children  whose  sanitary  surroundings 
are  not  good.  The  inflammation  begins  at  both  corners  of  the  mouth  and  ex- 
tends to  the  middle  line.  The  epithelium  becomes  whitened,  softened  and  easily 
detached.  The  hyperemia  and  inflammation  lead  the  child  constantly  to  lick 
its  lips,  hence  the  name.  A  streptococcus  infection  is  always  present  and  the 
disease  is  transmitted  from  one  child  to  another  by  the  use  of  common  drinking 
vessels,  towels,  etc.  The  most  important  factor  in  treatment  is  cleanliness. 
Corrective  work  in  the  upper  cervical  and  upper  thoracic  region  and  such 
other  treatment  as  is  indicated  by  the  general  health  of  the  child  facilitate 
speedy  recovery. 

THE  TEETH 

It  has  long  been  the  tendency  to  consider  the  v^rell-being  of 
the  teeth  from  the  standpoint  of  local  conditions  in  the  mouth 
alone,  and  to  consider  diseases  of  the  teeth  from  the  standpoint 
of  the  dentist  alone.  This  general  attitude  is  not  quite  justified 
by  the  facts  in  the  case.  The  teeth  are  well  supplied  with  nerves, 
both  sensory  and  vasomotor.  It  is  probable  that  trophic  nerves 
are  distributed  to  the  teeth  also.  So  far  as  the  effects  produced 
as  the  result  of  bony  lesions  of  the  cervical  and  upper  thoracic 
spinal  segments  there  is  no  reason  to  exclude  the  teeth  from  the 
laws  which  govern  other  tissues  of  the  oral  cavity.  Injury  to 
the  teeth  produces  reflex  muscular  contractions  of  the  muscles  of 
mastication  and  of  the  deep  spinal  muscles  of  the  upper  thoracic 
segments.  These  reflex  contractions,  especially  if  they  are  asso- 
ciated with  bony  lesions  of  the  upper  thoracic  vertebrae,  increase 
the  painfulness  of  the  injury  and  lessen  the  resistance  of  the  buccal 
membranes  to  infection. 

In  all  cases  of  pain  associated  with  the  teeth,  especially  that 
which  persists  for  hours  or  days,  vigorous  treatment  for  the  cor- 
rection of  lesions  of  the  mandible  and  hyoid,  the  relaxation 
of  the  muscles  already  mentioned,  and  the  establishment  of  better 
circulation  around  the  mandible  and  the  jaw  will  greatly  relieve 
the  pain  and  prevent  much  of  the  painful  after-effects  of  such 
dental  surgery  as  may  be  indicated  in  each  case. 

Pyorrhoea  Alveolaris  is  a  chronic  pyogenic  inflammation  of 
the  gums,  around  the  sockets  of  the  teeth,  due  to  a  specific  amoeba. 
Secondary  infections  with  pyogenic  bacteria  are  probably  invari- 
able. The  collections  of  pus  present  in  this  disease  may  serve  as  a 
constant  infection  of  the  body.  Many  vague  symptoms,  and  many 
cases  of  articular  and  other  inflammations  may  be  traced  to 
pyorrhea  alveolaris  and  to  abscesses  at  the  roots  of  teeth.  The 
microscopic  examination  of  the  fresh  pus  on  a  warm  stage  or  a 
warm  slide  in  a  warm  room  gives  the  diagnosis  of  pyorrhea.  In 
doubtful  cases  an  X-ray  examination  of  the  jaws  is  indicated.. 


26  THE  MOUTH 

The  patient  should  be  referred  to  a  dental  surgeon  for  local 
treatment.  The  correction  of  lesions  as  found  permits  more  rapid 
recovery. 

Abscesses  of  the  Teeth  and  Alveolar  Processes.  These  have 
been  too  long  held  as  of  merely  dental  interest.  Recent  studies 
of  disease  have  indicated  the  presence  of  pus  at  the  roots  of  the 
teeth  in  very  many  cases  of  toxemia,  supposed  to  be  autogenic, 
of  vague  symptoms  of  systemic  infections,  as  well  as  in  articular 
diseases. 

The  X-ray  is  of  inestimable  importance  in  these  cases,  and 
every  patient  who  suffers  from  vague  symptoms  of  toxemia  should 
have  X-ray  plates  made  of  the  mandible  and  the  maxillary  bones. 
The  ordinary  dental  examination  of  the  teeth  is  often  inefficient 
in  these  cases. 

Treatment.  The  patient  should  be  referred  to  a  dental  surgeon 
for  treatment.  The  pus  must  be  evacuated,  and  the  tooth  pulled 
or  filled  according  to  the  local  conditions. 

DISTURBANCES  OF  SALIVARY  SECRETION 

The  activities  of  the  salivary  glands  may  be  profoundly  modi- 
fied by  nervous  disturbances,  poisons,  or  circulatory  changes.  Two 
opposite  conditions  fnay  be  found. 

Hypersecretion  (Ptyalism).  This  is  an  abnormal  increase  in 
the  amount  of  saliva.  It  may  be  merely  uncomfortable  or  may 
amount  to  several  quarts  in  a  day's  time.  Almost  any  stomatitis, 
many  nervous  states,  gestation  or  menstruation  may  be  associated 
with  some  ptyalism.  Mercury,  arsenic,  iodine,  copper,  silver,  and 
some  other  metallic  poisons ;  pilocarpine,  tobacco,  muscarine  and 
certain  other  organic  poisons,  may  cause  marked  ptyalism.  It 
is  present  also  in  diseases  associated  with  nausea.  Bony  lesions 
do  not  often  cause  sufficient  hypersecretion  to  result  in  discomfort, 
though  these  may  increase  the  effects  of  other  etiological  factors. 

Hyposecretion  (Xerostomia,  aptyalism,  dry  mouth).  This  is  a 
diminution  in  the  amount  of  saliva,  and  may  result  in  serious  buccal 
disease.  The  dry,  red,  glazed  mouth  and  tongue,  sometimes  fis- 
sured, is  characteristic  and  is  very  painful.  Eating  and  speaking 
are  alike  painful,  sometimes  impossible  while  the  condition  exists. 
It  is  sometimes  present  to  a  slight  extent  in  acute  coryza,  but  in 
its  characteristic  form  is  found  as  a  neurosis,  more  often  in  women. 
It  is  probably  due  to  functional  disturbance  of  the  salivary  center 
in  the  medulla. 

Treatment.  Recovery  from  both  hypersecretion  and  hypose- 
cretion depends  upon  the  discovery  and  removal  «>f  the  causes  of 
the  conditions.  Drugs  must  be  stopped ;  occupational  causes  must 
be  eliminated;  disturbed  structural  relations  must  be  corrected. 


ACUTE  PAROTITIS  27 

Muscular  tension  in  the  neck  and  around  the  jaw  should  be 
removed ;  the  application  of  hot  compresses  or  of  ice  bags  may 
relieve  the  symptoms  for  a  time. 

ACUTE  PAROTITIS 

(Symptomatic  parotitis;  parotid  bubo) 

The  pyog-enic  bacteria,  the  infectious  agents  of  typhoid,  syph- 
ilis, cholera,  or  any  of  the  acute  fevers  or  exanthemata,  may  gain 
entrance  into  the  salivary  glands  and  set  up  an  acute  inflammatory 
process.  Mild  infection  leads  to  increased  secretion  and,  later, 
more  or  less  fibrous  induration  and  perhaps  stenosis  of  the  ducts. 
Sialoliths  may  be  formed.  The  secretion  may  accumulate  behind 
the  stenosis  and  a  cyst  of  considerable  size  be  formed.  Pyogenic 
infections  may  cause  suppuration  with  destruction  of  tissue. 

Reflex  muscular  contractions  cause  difficulty  in  mastication. 
The  jaws  may  be  set  so  firmly  as  to  suggest  beginning  trismus. 
Hypersensitive  areas  involve  most  of  the  tissues  around  the  neck 
and  the  jaws.    The  mastoid  process  is  often  painful  to  the  touch. 

Injury  to  the  pelvic  or  abdominal  organs  is  sometimes  followed 
by  acute  parotitis;  recovery  is  usually  uneventful,  so  far  as  the 
salivary  glands  are  concerned. 

Bony  lesions  affect  the  secretion  and  the  circulation  of  the 
salivary  glands ;  in  order  of  frequency  the  mandible,  hyoid,  atlas 
occiput,  axis,  and  the  upper  thoracic  vertebrae  and  ribs  and  the 
clavicle  have  been  reported  in  connection  with  acute  parotitis. 

Treatment.  The  atlas  and  axis  seem  to  be  most  important 
from  the  structural  standpoint.  "The  gland  involved  is  generally 
on  the  side  of  the  transverse  process  which  is  most  anterior" 
(McConnell).  "Pushing  the  surrounding  tissues  toward  the 
aflfected  glands,  exerting  no  pressure  directly  upon  them,  reestab- 
lishes lymph  drainage"  (Emery).  Other  lesions  often  found 
include  the  upper  cervical  and  the  upper  thoracic  vertebrae,  the 
upper  ribs  and  the  clavicle.  These  bony,  and  all  muscular  and 
ligamentous  lesions,  should  be  corrected  wherever  found. 

Pcognosis.  If  the  causes  can  be  removed,  recovery  is  to  be 
expected.  When  there  has  been  much  increase  in  the  interstitial 
connective  tissues,  the  gland  may  not  return  to  its  original  size. 

EPIDEMIC  PAROTITIS 

(Mumps).    See  Acute  Infectious  Diseases 

CHRONIC  PAROTITIS 

(Mikulicz's  disease) 
This  occurs  when  any  agent  irritating  to  the  salivary  glands 
is  long  continued.     Probably  the  bony  lesions  mentioned  in  con- 


28  THE  MOUTH 

nection  with  acute  parotitis  are  more  frequently  important  etiolog- 
ically  in  chronic  than  in  the  acute  diseases  of  these  glands.  The 
place  of  the  bony  lesion  is  found  in  its  influence  in  predisposing 
to  infection,  and  in  delaying  recovery.  Mercury  poisoning  is  an 
important  factor  in  the  chronic  parotitis  found  in  certain  syphilitic 
cases.  The  use  of  calomel  is  of  less  importance  in  non-syphilitic 
cases  than  formerly.  After  mumps  and  other  forms  of  acute  par- 
otitis a  chronic  inflammation  may  persist.  Lead  poisoning,  chronic 
nephritis,  and  certain  obscure  gastro-intestinal  diseases  may  cause 
chronic  parotitis.  Diseases  of  the  ovaries  and  the  testicles  are 
sometimes  associated  with  mild  chronic  parotitis.  Inflammation 
of  the  lachrymal  glands  is  a  frequent  complication. 

The  treatment  is  that  of  the  causative  factors.  Mercury  must 
be  stopped,  if  it  is  being  used  as  a  drug  or  if  it  is  an  occupation-poi- 
soning. The  same  is  true  of  lead.  Bony  lesions  are  to  be  corrected 
as  speedily  as  is  possible  under  the  circumstances.  The  treatment 
for  acute  parotitis  is  useful,  especially  in  sub-acute  cases. 

Prognosis.  Increase  in  the  interstitial  tissues  is  usually  marked, 
and  the  gland  can  hardly  be  expected  to  return  to  its  original  size, 
especially  if  the  disease  is  of  long  standing.  Symptomatic  recovery 
is  usually  secured,  if  the  treatment  is  vigorously  prosecuted. 

OTHER  ABNORMALITIES 

The  salivary  glands  are  rarely  the  seat  of  neoplasms.  The  only 
treatment  is  surgical,  when  treatment  is  required  at  all. 

Glass  blowers  and  those  who  play  on  wind  instruments  may 
suffer  from  distension  of  Steno's  duct  and  even  of  the  parotid 
gland  with  air.  If  disturbing  symptoms  are  present  the  condition 
can  be  removed  by  catheterization.  Change  of  occupation  may  be 
necessary. 


CHAPTER  II 
DISEASES  OF  THE  ESOPHAGUS 

INFLAMMATIONS 

Esophagitis  or  inflammation  of  the  esophagus  may  be  acute  or 
chronic,  and  may  be  either  primary  or  secondary. 

Acute  Esophagitis  arises  from  intense  mechanical,  thermal  or  chemical 
irritants;  as  a  secondary  complication  of  the  specific  fevers;  toward 
the  end  in  wasting  diseases;  in  infants  as  a  purely  catarrhal  type  often  without 
apparent  cause;  and  from  local  disease. 

Congestion  of  the  mucosa  and  exfoliation  of  the  superficial  epithelium 
occurs.  The  normally  scanty  secretion  is  increased.  Shallow  erosions  result, 
situated  mostly  on  the  tops  of  the  longitudinal  folds.  These,  healing,  leave 
small  scars. 

Phlegmonous  or  diffuse  suppurative  esophagitis  may  be  traumatic, 
may  be  due  to  foreign  bodies  or  corrosive  substances,  with  subsequent  infection. 
It  occurs  more  commonly  by  extension  from  the  pharynx,  stomach,  periesopha- 
geal lymph  nodes,  vertebral  column  or  the  cricoid  cartilage. 

This  form  begins  as  a  purulent  infiltration  of  the  submucosa,  leading  to 
localized  or  diffused  collections  of  pus,  the  mucosa  is  reddened  and  undermined 
and  fistulous  openings  are  formed.  The  surrounding  tissues  are  sometimes 
involved  and  the  abscess  may  discharge  into  the  larynx,  trachea,  rarely  into  the 
pleura  and  mediastinum. 

Pustular.  The  papules  of  smallpox  in  the  mucosa  may  rupture,  form- 
ing ulcers. 

Membranous.  This  is  not  uncommon  in  variola,  measles,  scarlatina, 
typhoid  and  typhus,  pyemia,  cholera,  chronic  Bright's  disease,  pneumonia,  tuber- 
culosis, and  the  gastro-intestinal  catarrh  of  infants.  The  fibrinous  deposit  is 
rarely  generalized,  but  is  usually  confined  to  the  tops  of  the  folds.  Ulceration 
may  occur  with  stenosis  of  the  lumen  from  cicatricial  contraction.  True  diph- 
theria of  the  esophagus  is  rare. 

Exfoliative.  (Esophagitis  dessicans  superficialis.)  The  etiology  is 
not  clear;  in  some  cases  is  due  to  corrosives  but  usually  occurs  in  neurotic  indi- 
viduals. The  desquamation  of  the  lining  epithelium  takes  place  in  large  flakes 
or  as  a  complete  cylinder. 

Corrosive  Esophagitis  is  due  to  corrosive  poisons,  chiefly  acids 
and  alkalies,  as  concentrated  lye,  carbolic  and  sulphuric  acids.  It  is  a  necrosing 
inflammation  resulting  in  serious  contracture  of  the  lumen  if  the  patient  survives. 

Catarrhal  may  follow  the  acute  form ;  may  arise  above  a  stricture, 
or  may  be  the  result  of  excessive  alcoholism.  The  mucosa  resembles  that  of 
chronic  catarrhal  inflammations  elsewhere.  Papillomatous  or  polypoid  growths 
may  occur,  and  leukoplakia  may  be  present.  The  tenacious  mucus  or  mucopus, 
the  thickened  muscular  wall,  and  sometimes  superficial  ulcerations  are  the  usual 
findings. 

Follicular.  The  mucous  glands  are  involved,  the  lumina  are  obstructed 
and     there     is     excessive     secretion,     which     leads     to     dilatation     of     the 

29 


30  THE  ESOPHAGUS 

glands  and  ducts  into  small  cysts.    There  is  round-celled  infiltration  around  the 
glands  which  may  result  in  abscess  formation. 

Diagnosis.  The  principal  manifestations  of  these  inflammations 
are :  a  dull  pain  under  the  sternum,  difficult  swallowing,  tenderness 
over  the  cervical  portion,  and  a  copious  mucoid  secretion  which  is 
regurgitated  or  passes  into  the  stomach.  Cicatricial  changes 
eventually  lead  to  obstruction. 

In  the  chronic  form,  in  alcoholics,  there  is  morning  vomiting  of 
esophageal  mucus,  sometimes  mixed  with  the  contents  of  the 
stomach.  If  the  vomitus  is  only  from  the  esophagus,  the  reaction 
is  alkaline,  but  if  gastric  contents  are  present  it  is  acid. 

Foreign  bodies  may  cause  more  or  less  complete  obstruction  and 
lead  to  phlegmonous  inflammation  or  even  to  perforation. 

Treatment.  The  treatment  of  all  forms  includes  the  relief  of 
the  underlying  condition  if  the  disease  is  secondary ;  correction  of 
the  cervical  vertebrae  which  might  interfere  with  the  vagus ;  atten- 
tion to  the  first  to  fifth  thoracic;  raising  and  spreading  the  ribs, 
especially  at  the  sternal  ends. 

The  diet  must  be  absolutely  non-irritating  and  liquid.  It  may 
be  advisable  to  employ  rectal  feeding  for  a  few  days. 

CARCINOMA  OF  THE  ESOPHAGUS 

This  is  the  most  important  new  growth  and  may  be  either  pri- 
mary or  secondary,  occurring  most  frequently  in  males  between 
50  and  60  years,  particularly  in  smokers  and  drinkers. 

Diagnosis.  The  symptoms  are  progressive  dysphagia,  and 
great  pain  which  may  become  so  extreme  that  emaciation  occurs 
rapidly.  Regurgitation  may  take  place  at  once  or  be  deferred  for 
ten  or  fifteen  minutes,  according  to  the  location  and  the  amount 
of  dilatation.  The  ejected  material  may  be  mixed  with  blood  and 
cancerous  fragments.  The  cervical  glands  are  frequently  enlarged 
and  may  give  the  first  indication  of  the  trouble.  The  X-ray  will 
give  information  as  to  position  and  extent  of  involvement. 

For  diagnosis  it  is  important  to  exclude  external  pressure  from 
an  aneurysm  or  tumor;  to  exclude  cicatricial  stricture  and  foreign 
bodies ;  and,  lastly,  to  pass  the  sound  with  the  greatest  possible 
care.  Auscultation  on  the  left  side  of  the  spine  may  detect  altered 
esophageal  murmur. 

Treatment.  The  patient  may  be  made  more  comfortable  by 
thorough  treatment  from  the  occiput  to  the  eleventh  dorsal.  Rectal 
feeding  or  gavage  may  be  necessary  from  the  first,  but  should  be 
postponed  as  long  as  there  is  not  severe  pain.  Gastrostomy  may 
prolong  the  patient's  life  in  more  comfort  than  without  it. 

Prognosis.  The  case  is  hopeless,  patients  dyiyg  in  from  six 
months  to  a  year  from  asthenia  or  from  sudden  perforation. 


STRICTURE  31 

ALTERATIONS  IN  THE  LUMEN  OF  THE  ESOPHAGUS 

The  alterations  comprise  two  forms — stenosis  or  stricture,  and 
dilatation. 

Stenosis  may  be  developmental  or  acquired. 

The  extrinsic  causes  are  pressure  from  enlarged  glands,  aneu- 
rysms, and  tumors  of  the  lungs,  pleura,  or  mediastinum. 

The  intrinsic  causes  include  all  forms  of  local  inflammations, 
phlegmon,  growths  of  thrush  or  tissue,  cicatricial  contraction  of 
the  wall  from  trauma,  corrosives,  syphilis,  diphtheria,  and  foreign 
bodies. 

Diagnosis.  The  symptoms  depend  upon  the  position  and  the 
degree  of  narrowing  present.  There  is  slowly  increasing  dysphagia 
which  is  common  to  all  sites.  Regurgitation  of  food  is  the  most 
common  symptom ;  if  the  stricture  is  high,  the  food  may  be  returned 
immediately,  if  low  after  a  slightly  longer  interval.  Pain  and 
emaciation  follow  when  the  narrowing  is  great.  After  all  intra- 
thoracic diseases  are  excluded,  the  passage  of  an  esophageal  bougie 
determines  the  positio::,  and  the  degree.  The  X-ray  may  give  an 
absolute  diagnosis. 

Treatment.  If  mal-adjustments  are  found  affecting  the  innerva- 
tion and  the  blood  supply  of  the  esophagus,  see  what  correction 
will  do  for  the  case.  If  the  cause  is  from  cicatricial  tissue,  the 
passage  of  a  bougie  to  secure  progressive  dilatation  may  effect 
relief.  If  the  stricture  is  impassable,  gastrostomy  is  the  only  means 
possible. 

Prognosis.  The  prognosis  is  unfavorable  except  in  cases  of 
cicatricial  contraction. 

Spasmodic  Stricture  or  Esophagismus  occurs  in  neurotic  indi- 
viduals, especially  young  women,  and  also  in  elderly  men,  especially 
if  hypochondriac. 

Diagnosis.  The  trouble  commences  suddenly,  usually' during  a 
meal,  the  food  is  retarded  for  some  time,  then  either  passes  on  to  the 
stomach  or  is  returned.  It  is  attended  by  severe  pain  and  retching. 
There  is  little  emaciation. 

On  passing  the  sound,  stricture  may  be  found  at  different  sites 
on  different  days,  or  it  may  be  passed  with  ease  at  times.  In  some 
individuals  the  sound  can  always  be  passed  without  difficulty. 

Treatment.  The  main  treatment  is  that  of  the  neurotic  condi- 
tion. Some  specific  lesion,  especially  in  the  upper  thoracic  region, 
may  be  found  that  has  produced  this  particular  attack.  When  the 
lesion  is  corrected  the  spasm  disappears.  Psycho-analysis  is  useful 
in  hysterical  cases. 

As  a  last  resort,  passage  of  a  full  sized  bougie  two  or  three  times 
a  week  may  be  necessary. 


32  THE  ESOPHAGUS 

Dilatation  or  Diverticulum  of  the  'Esophagus  occurs  from  pres- 
sure from  within  the  lumen  or  from  traction  from  inflammatory 
conditions  outside  of  the  tube,  or  may  be  congenital.  The  X-ray 
may  give  information  as  to  the  location  and  extent  of  the  change 
in  the  lumen  or  the  size,  location  and  shape  of  diverticulum. 

The  most  common  symptom  is  regurgitation  of  the  food. 

Treatment.  The  causal  condition  must  be  cared  for  first.  Sur- 
gery is  a  last  resort. 

Cardiospasm  is  a  spasm  of  the  circular  muscle  fibers  at  the 
cardiac  orifice  of  the  stomach.  It  causes  a  sensation  of  discomfort 
immediately  after  swallowing,  and  leads  to  dilatation  of  the  esoph- 
agus. Since  section  of  the  vagus  causes  the  condition,  in  cats, 
(Cannon)  it  seems  probable  that  inhibitory  influences  acting  on 
the  vagus  center  might  be  responsible.  At  autopsy  these  muscle 
fibers  are  found  hypertrophied.  Rather  rarely  the  condition  is 
associated  with  ulcer  or  cancer  of  the  stomach. 

Treatment.  Correction  of  lesions  affecting  the  vagal  or  the 
splanchnic  centers  may  give  relief.  Gradual  and  careful  dilating 
with  special  instruments  has  been  successful. 

FOREIGN  BODIES  IN  THE  ESOPHAGUS 

Coins,  needles,  pins,  bits  of  metal,  bones  from  fish  and  othei 
foods,  and  many  other  foreign  substances  are  often  swallowed  by 
accident  or  otherwise,  and  become  lodged  in  the  esophagus. 

The  history  of  the  case  should  lead  to  an  X-ray  examination  and 
thus  the  recognition  of  the  exact  location  of  the  body.  Its  removal 
can  be  secured  under  the  fluoroscope,  if  necessary. 

After  such  an  operation  the  food  should  be  bland  and  liquid 
The  treatment  advised  for  acute  esophagitis  should  then  be  em- 
ployed. 


CHAPTER  III 
NEUROSES  OF  THE  STOMACH 

The  neuroses  are  those  disturbances  of  gastric  functions  which 
depend  primarily  upon  disturbances  in  the  nervous  control  of  the 
organ,  but  which  are  not  associated  with  recognizable  structural 
changes  in  the  gastric  walls.  These  are  classified  briefly  in  the  fol- 
lowing outline;  the  description  of  each  is  given  but  the  etiology 
and  the  treatment  are  given  for  all,  since  these  factors  are  prac- 
tically identical  for  all  classes  of  neurosis. 

Care  in  diagnosis  is  especially"  urged  when  gastric  neurosis  is 
suspected,  since  organic  disease  of  the  stomach  may  simulate  nerv- 
ous disease,  and  an  error  in  diagnosis  may  cause  fatal  delay  in 
efficient  treatment  for  organic  disease. 

The  neuroses  include  variations  in  secretion,  sensation,  and 
motion. 

The  secretory  neuroses  include  those  variations  in  the  gastric  juice  due  to 
disturbed  nervous  control,  and  not  associated  with  organic  disease  of  the  stomach. 

Hyperchlorhydria  (hyperacidity)  is  a  condition  in  which  the  gastric  juice 
from  the  fasting  stomach  or  after  a  test  meal  contains  greater  than  the  normal 
percentage  of  hydrochloric  acid.  It  is  doubtful  whether  a  truly  hyper-acid  juice 
is  ever  secreted;  variations  in  the  dilution  and  in  the  combining  substances, 
mucus,  etc.,  present  in  the  stomach  probably  cause  the  symptoms  as  found. 
These  include  a  vague  discomfort  or  burning  pain,  with  weight  and  pressure  in 
the  epigastrium,  perhaps  with  acid  eructations,  regurgitation  and  pyrosis,  some- 
times nausea  and  vomiting.  Severe  headache  and  vertigo  are  common.  There  is 
often  a  sinking  feeling  before  meals.  The  pain  lasts  from  one  to  three  hours, 
and  is  relieved  by  vomiting  or  by  taking  some  proteid  food  or  an  alkali.  It  is 
usually  remittent,  returning  upon  grief  or  worry,  or  without  obvious  cause, 
and  finally  becomes  continuous.     The  bowels  are  constipated. 

The  usual  physical  examination  discloses  a  moderate  diffuse  epigastric 
tenderness,  with  perhaps  a  slight  dilatation. 

Gastric  Analysis:  After  Ewald's  meal  (one  hour  after),  an  excess  of 
free  HCl ;  three  to  four  hours  after  a  Leube-Rigel  meal,  the  meat  is  digested 
but  the  starches  remain  unchanged. 

Hypochlorhydria  (anacidity;  suhacidity;  achylia  gastrica  nervosa),  is  a 
diminution  or  absence  of  HCl,  common  in  gastric  cancer,  pernicious  anemia, 
and  in  atrophic  gastritis,  occurring  not  infrequently  as  a  neurosis  in  hysteria, 
neurasthenia,   and  tabes  dorsalis. 

The  symptoms  begin  with  a  sense  of  fullness  and  oppression  after  meals 
which  may  last  all  day,  flatulence,  headache,  drowsiness,  constipation,  with  the 
tongue  pale,  broad,  flabby,  and  indented  by  the  teeth. 

The  gastric  analysis  shows  total  acidity  about  4 ;  HCl  and  often  the  fer- 
ments absent;  mucus  absent;  lactic  acid  absent  except  in  traces. 

Hypersecretion  is  an  excessive  secretion  of  hydrochloric  acid  and 
gastric  juice  in  the  fasting  stomach,  and  is  of  two  forms,  periodic  or  inter- 
mittent (gastroxynis)  and  the  continuous  or  chronic  form. 

33 


34  NEUROSES  OF  THE  STOMACH 

Gastroxynis.  The  patient  is  apparently  well  when  he  is  seized  with 
a  sensation  of  epigastric  uneasiness  which  develops  into  pain  and  is  followed 
by  nausea  which  is  persistent.  Vomiting  of  a  large  amount  of  very  acid  gastric 
juice  ultimately  tinged  with  bile  occurs.  This  may  be  ejected  at  intervals  of  a 
few  hours.  The  throat  may  become  raw  and  sore.  The  attack  as  a  whole  lasts 
from  one  to  three  hours,  terminating  abruptly,  but  tends  to  recur  at  varying 
intervals.  If  the  attacks  recur  one  upon  another,  the  condition  merges  into  the 
continuous  form.  The  paroxysms  occur  most  often  at  night  or  in  the  early 
morning.    Tabes  dorsalis  should  be  strongly  suspected. 

Continuous  Hypersecretion.  The  early  symptoms  are  those  of  either 
hyperchlorhydria  or  gastroxynis.  The  epigastric  pain  becomes  habitual 
after  meals,  vomiting  of  an  acid  fluid,  at  first  occasionally,  becoming  once  or 
more  daily,  commonly  after  breakfast.  The  condition  may  be  associated  with 
pyloric  stenosis  or  gastrectasis.  Gastric  analysis :  An  abnormally  large  amount 
of  acid  gastric  juice  free  from  fragments  of  food  is  obtained  from  the  fasting 
stomach. 

The  sensory  neuroses  include  pain  and  variations  in  the  normal  gastric 
sensations,  not  due  to  organic  disease  of  the  stomach.  The  "nervous  dyspepsia" 
of  older  writers  was  chiefly  sensory. 

Gastralgia  is  a  paroxysmal  gastric  pain  which  may  be  a  pure  neurosis  or 
may  occur  as  a  symptom  of  organic  trouble  in  gastric  ulcer,  cancer,  or  in 
gastric  crises  of  tabes.  The  pain  is  relieved  by  taking  food  and  is  most  apt 
to  occur  when  the  stomach  is  empty.  The  attack  is  frequently  preceded  by 
slight  nausea,  or  epigastric  pressure,  salivation,  faintness,  vertigo,  or  headache. 
Shortly  afterward,  a  severe  and  agonizing  pain  begins  in  the  epigastrium, 
radiates  to  the  back,  and  along  the  costal  margins  especially  to  the  left,  ex- 
tending in  some  cases  to  the  scapula  and  entire  abdomen..  The  face  is  pale 
and  anxious,  the  hands  and  feet  cold,  the  skin  cool  and  wet,  and  the  body 
curved  forward  with  the  abdomen  hollow.  The  attack  lasts  from  a  few 
minutes  to  several  hours. 

Pressure  with  the  flat  of  the  hand  is  often  grateful  during  an  attack. 
There  is  a  slight  tenderness  in  the  epigastrium.  Gastric  analysis  shows  the 
HCl  often  in  excess. 

Paroxysmal  Bulimia  (Hyperorexia)  is  a  condition  seen  in  hysteria, 
neurasthenia,  migraine,  epilepsy,  exophthalmic  goitre,  and  cerebral  tumors. 
It  is  characterized  by  sudden  attacks  of  burning  epigastric  pain,  faintness,  head- 
ache, and  excessive  hunger,  especially  at  night,  the  paroxysm  being  often  relieved 
by  taking  food. 

Anorexia  Nervosa.     Death  may  be  due  to  this  absolute  loss  of  appetite, 

which  is  very  extreme,  the  sight  of  food  exciting  a  spasm.  It  occurs  as 
an  hysterical  manifestation  in  girls  of  IS  to  20  years.  The  patient  is  restless, 
takes  to  bed,  emaciation  is  progressive  and  frequently  reaches  an  extreme 
degree,  the  skin  becomes  dry  and  brawny,  contractures  of  the  lower  extremities 
may  develop,  and  death  has  been  recorded. 

Gastric  Hyperesthesia.  This  is  a  condition  in  which  a  sense  of  pressure, 
burning,  fullness  or  weight,  or  gnawing  pain,  with  tenderness  in  the  epigas- 
trium, occurs  during  the  process  of  digestion.  The  gastric  analysis  shows  a 
normal  gastric  juice  and  digestion. 

The  motor  neuroses  include  variations  in  the  tone  of  the  gastric  wall 
and  variations  in  the  peristaltic  waves,  not  due  to  organic  disease. 

Supermotility  (hyperkinesis)  is  an  increase  in  the  normal  motor  activity 
of  the  stomach,  and  causes  a  too  early  discharge  of  the  ingesta  into  the 
duodenum.  It  is  best  recognized  by  the  radiograph  or  fluoroscopic  examination, 
which  also  indicates  the  presence  or  absence  of  ulcer. 

Nervous  Vomiting  occurs  in  children  and  adults.  The  stomach  con- 
tents are  ejected  without  preliminary  nausea  and  strainings  this  usually  takes 


ETIOLOGY  35 

place  shortly  after  eating  and  at  irregular  intervals.  The  general  health  is 
unimpaired.  Primary  periodic  vomiting  may  occur  as  a  neurosis  in  otherwise 
perfectly  healthy  persons,  especially  women  while  menstruating.  The  condi- 
tion is  associated  with  deficient  tone  of  the  muscular  ring  around  the  cardiac 
opening,  and  appears  to  be  due  to  defective  vagal  innervation. 

Peristaltic  unrest  (tormina  ventricuH)  is  an  annoying  condition  seen 
after  eating  in  which  the  peristaltic  movements  are  hyperactive,  causing  loud 
borborygmi,  gurgling,  and  splashing.  These  are  intensified  by  emotion,  and 
may  extend  to  the  intestines.  The  condition  is  a  frequent  symptom  of  hysteria 
or  neurasthenia. 

Nervous  eructations  (aerophagia)  is  characterized  by  annoying  belchings 
of  air  which  has  been  swallowed.  It  continues  for  hours  or  days,  or  occurs 
in  paroxysms  which  are  excited  by  emotion.  Hysterical  women  and  children 
or  neurasthenic  patients  are  most  often  so  affected.  Anxiety,  palpitation, 
epigastric  fullness  and  distress  may  attend  the  paroxysms. 

Rumination  (merycismus)  is  a  rare  condition  occurring  especially  in  the 
feeble-minded,  or  idiotic  or  insane,  in  which  the  patient  regurgitates  the  food 
and  chews  the  cud. 

Spasm  of  the  pylorus  may  cause  retention  of  the  food  in  the  stomach 
beyond  the  normal  limit    It  is  probably  associated  with  variations  in  secretion. 

Etiology.  Rarely  a  gastric  neurosis  is  due  to  a  single  factor. 
The  predisposing  causes  include  a  neurotic  inheritance ;  unhygienic 
conditions  such  as  poor  ventilation,  worry  or  over-work,  improper 
foods  or  improper  habits  of  eating;  unpleasant  surroundings  at  meal 
time,  and  especially  eating  under  the  influence  of  haste  or  excite- 
ment or  with  a  sense  of  disgust  at  the  appearance  of  the  food, 
the  service,  or  any  other  factor  which  causes  annoyance;  imper- 
fect mastication  due  to  habit,  bad  teeth,  or  pyorrhea,  or  the  habitual 
use  of  cathartics. 

Vertebral,  rib,  or  other  bony  lesions  are  probably  the  most  im- 
portant causes  of  gastric  neuroses.  These  may  act  for  many  years 
as  irritating  factors  before  the  onset  of  recognizable  symptoms ;  in 
such  cases  questioning  usually  elicits  slight  gastric  symptoms  which 
have  been  long  present.  The  lesions  involving  the  mid-thoracic 
region,  especially  with  rotation,  are  most  common.  The  fifth  to 
the  ninth  thoracic  vertebrae  are  almost  invariably  found  rigid,  and 
usually  the  spinous  processes  of  these  are  approximated.  Cervical 
lesions  are  practically  constant.  G.  W.  Bumpus  gives  lesions  of 
the  ensiform  process  an  important  place  in  the  etiology  of  gastric 
neuroses.  Reflex  muscular  contractions  affect  the  regions  just  men- 
tioned, and  also  the  muscles  of  the  anterior  neck  region.  Hyper- 
sensitiveness  is  usually  widespread  and  varies  from  day  to  day  in 
the  same  individual.  Often  the  tissues  near  the  vertebral  subluxa- 
tions are  analgesic ;  in  such  cases  the  correction  of  the  lesions  is 
often  followed  by  the  appearance  of  considerable  pain.  This  may 
last  for  some  days,  and  the  patient  should  be  warned  of  this  pos- 
sibility. 

Among  the  less  frequent  causes  of  gastric  neuroses  may  be 
mentioned  eye  strain,  nasal  polyps,  hard  ear  wax,  adenoids,  organic 


36  NEUROSES  OF  THE  STOMACH 

disease  of  the  pelvic  organs  in  both  sexes  (especially  of  the  rectum, 
ovaries,  or  testes),  and  other  causes  of  nervous  irritation. 

Repressions  of  old  emotional  storms,  especially  of  disgust,  are 
sometimes  important  in  etiology.  This  can  only  be  certainly  deter- 
mined by  the  use  of  psycho-analysis,  carefully  adapted  to  the  indi- 
vidual needs. 

Diagnosis.  The  diagnosis  of  the  gastric  neuroses  can  only  be 
made  after  all  organic  diseases  have  been  ruled  out.  The  blood 
and  urine  show  only  the  characteristics  of  the  neurotic  diathesis 
with  signs  of  malnutrition,  if  this  be  present.  The  X-ray  is  often 
the  only  method  of  distinguishing  an  organic  from  a  nervous  gas- 
tric disorder.  Gastric  analysis  shows  the  distinctive  secretory  dis- 
turbances, but  in  most  cases  does  not  determine  whether  this  is  due 
to  nervous  or  to  organic  changes.  The  recognition  of  the  under- 
lying neurosis  should  not  be  considered  of  too  great  importance, 
since  neurotic  individuals  are  certainly  not  less  subject  to  organic 
diseases  than  are  those  nervously  sound,  and  in  many  instances  a 
neurosis  is  itself  due  to  a  previously  existing  gastric  disease.  Even 
after  all  care  has  been  taken  in  diagnosis,  cases  supposed  to  be 
neurotic  may  develop  cancerous  cachexia  or  a  fatal  hemorrhage 
from  ulcer;  on  the  other  hand,  cases  in  which  a  fatal  outcome 
from  cancer  is  expected  may  recover  apparently  perfect  health. 

When  organic  disease  has  been  recognized,  the  presence  of  an 
associated  neurosis  may  be  important  in  magnifying  and  compli- 
cating the  symptoms.  For  this  reason,  the  treatment  advised  for 
the  neuroses  may  often  be  employed  with  excellent  palliative 
effects,  even  in  the  most  sierious  organic  gastric  disease. 

Treatment.  The  treatment  includes  the  removal  of  every  etio- 
logical factor  possible.  The  correction  of  structural  lesions  must 
be  secured  with  the  least  possible  irritation,  as  a  rule,  though  in 
long  standing  cases  with  hyposecretion  and  akinesis  the  use  of  ener- 
getic and  rather  stimulating  methods  in  the  necessary  corrective 
manipulations  gives  excellent  results.  In  the  cases  with  hyper- 
kinesis  and  hypersecretion,  especially  with  considerable  pain 
at  times,  the  manipulations  required  for  correction  should  be  given 
in  a  slow  and  gradual  way,  carefully  avoiding  any  jerky  or  sudden 
methods.  Some  exceptions  are  found  to  these  rules,  but  in  gen- 
eral it  is  best  to  secure  corrections  vjery  gently  in  those  cases  in 
which  the  normal  activities  and  sensations  are  increased,  and  to 
employ  more  energetic  and  stimulating  methods  when  the  normal 
activities  seem  to  be  diminished. 

Carefully  graded  exercises  are  useful,  both  for  the  direct  and 
for  the  psychological  effect. 

Thorough  inhibition  of  the  splanchnics  and  the  application  of 
hot  packs  are  beneficial  in  gastralgia. 


TREATMENT  27 

Properly  fitted  corsets  may  give  relief  in  neurotic  women.  In 
cases  in  which  vagal  functions  seem  at  fault  (vomiting,  nausea, 
and  others)  the  patient  should  eat  while  lying  in  bed,  or  in  a  semi- 
reclining  position,  so  that  the  head  is  supported  by  pillows,  with 
no  weight  upon  the  neck. 

The  dietetic  requirements  are  varied.  It  is  often  best  to  advise 
that  each  meal  consist  of  a  single  article  of  food.  Very  often,  for 
the  first  few  days,  the  patient  may  be  allowed  any  one  article  he 
chooses,  at  each  meal,  and  only  one.  From  his  account  of  symp- 
toms during  these  few  days,  and  the  eflfect  produced  upon  his  diges- 
tion, the  permanent  dietetic  instructions  may  be  safely  determined. 
Often  five  or  even  seven  small  meals  are  better  than  two  or  three 
ordinary  meals.     Exclusive  milk  diet  may  be  useful. 

Perhaps  more  important  than  the  actual  quality  of  food,  in 
purely  nervous  disturbances,  is  the  manner  of  eating.  Leisurely 
habits,  a  calm  mental  state,  and  eating  in  a  quiet  clean  place,  of 
food  that  appears  clean  and  attractive,  is  sometimes  the  most  impor- 
tant requisite  to  recovery. 

A  glass  of  hot  water  half  an  hour  before  meals,  or  upon  arising 
in  the  morning,  or  just  before  retiring  at  night,  all  give  relief  in 
some  cases.  Half  an  hour  of  rest,  lying  upon  the  right  side,  relieves 
the  symptoms  in  many  patients.    Every  case  is  a  law  to  itself. 

In  some  cases  the  use  of  psycho-analytic  methods  is  advisable. 
It  is  usually  best  to  delay  this  until  structural  corrections  have  been 
made  and  relief  of  symptoms  is  still  delayed. 

In  hyperchlorhydria,  an  exclusive  meat  diet  is  often  recom- 
mended. 

In  hypochlorhydria,  a  light,  easily  digested,  mixed  diet  is  best. 

In  hyperaesthesia,  rectal  feeding  is  sometimes  necessary. 

In  hypersecretion,  lavage  is  useful. 

In  atony,  the  meals  must  be  small  and  frequent  and  the  fluids 
limited;  if  with  dilatation,  lavage  is  useful. 

Prognosis,  In  all  neuroses  the  prospect  of  life  is  good,  perhaps 
even  better  than  for  normal  individuals ;  the  average  neurotic  takes 
excellent  care  of  himself.  Recovery  is  usually  slow,  with  many 
recurrences.  If  a  patient  has  a  fairly  good  heredity,  and  is  willing 
to  obey  instructions  and  to  submit  to  the  treatment  for  the  correc- 
tion of  the  lesions,  permanent  recovery  may  be  expected.  Unfor- 
tunately, such  patients  usually  cease  being  treated  when  the  symp- 
toms subside,  and  bony  lesions  are  allowed  to  persist.  Recurrences 
are  almost  inevitable  if  the  underlying  lesions  are  not  corrected,  or 
if  the  original  causes  of  the  neurosis  persist  or  recur. 


CHAPTER  IV 
ORGANIC  GASTRIC  DISEASES 

ACUTE  CATARRHAL  GASTRITIS 

(Simple  gastritis;  gastric  fever;  bilious  fever;  acute  indigestion;  subacute  gas- 
tritis;   acute    dyspepsia;    acute    catarrh    of    the    stomach) 

Acute  catarrhal  gastritis  is  an  inflammation  of  the  stomach 
which  may  be  infectious  or  toxic  in  origin,  or  may  occur  as  a 
complication  of  other  diseases,  and  is  characterized  by  distress  and 
tenderness  of  the  stomach,  severe  epigastric  pain,  vomiting  and 
slight  constitutional  disturbances. 

Etiology.  The  exciting  causes  are:  ingestion  of  unripe  fruits, 
decomposed  animal  substances,  irritant  poisons,  the  abuse  of  alco- 
hol, tea,  coffee,  etc.  The  predisposing  causes  are  lesions  of  the 
spine  from  the.  fourth  to  ninth  or  the  ribs,  injury  or  irritation 
of  the  vagi,  especially  the  right,  or  sudden  strain  or  blow  affecting 
the  mid-thoracic  spinal  column.  Even  wholesome  food,  taken  dur- 
ing extreme  fatigue,  or  when  serious  emotional  disturbance  is 
present,  may  precipitate  an  attack  of  acute  gastritis. 

Pathologfy.  The  mucosa  shows  the  usual  inflammatory  changes  of 
an  inflamed  mucous  membrane.  The  various  epithelial  cells  of  the  numerous 
glands  may  become  highly  granular,  undergo  mucoid  degeneration  or  des- 
quamate. There  may  be  minute  extravasations  of  blood,  hemorrhagic  erosions, 
pustules,  or  aphthous  patches.  The  submucosa  is  infiltrated  and  the  whole  wall 
may  be  congested.     The  pyloric  region  is  usually  affected. 

A  false  membrane  may  be  found  in  diphtheria,  pneumonia  and  typhus; 
pustules   in  smallpox  and  multiple  abscesses   in  pyemia. 

Diagnosis.  The  onset  is  sudden  in  severe  cases,  with  epigastric 
pain  passing  through  to  the  back,  accompanied  by  deep  diffuse 
tenderness ;  the  tongue  is  furred,  the  breath  heavy ;  there  is  vomit- 
irig  at  first  of  the  stomach  contents  of  undigested  food,  then  viscid 
mucus,  and  finally,  bilious  matter  or  blood-streaked  material. 
There  is  slight  fever  with  marked  prostration ;  flashes  of  heat  with 
sensations  of  burning  in  the  palms  of  the  hands  and  the  soles  of 
the  feet  may  be  present.  In  mild  cases,  the  symptoms  may  be 
only  abdominal  distress,  nausea,  tongue  heavily  coated,  and  eruc- 
tations ending  in  vomiting,  which  brings  relief.  There  is  either 
constipation  or  diarrhea. 

Reflex  muscular  contractions  in  the  midthoracic  region  are  con-  • 
stant,  whether  preexisting  lesions  had  been  recognizable  or  not. 
This  spinal  area  is  hypersensitive  and  the  tissues  have  a  stiffened, 
pasty  feeling  on  palpation. 

38 


ACUTB  GASTRITIS  39 

The  region  of  the  stomach  is  hypersensitive  to  pressure.  When 
a  strictly  localized  area  of  tenderness  over  the  pyloric  region  per- 
sists a  gastric  ulcer  should  be  suspected. 

Gastric  analysis  shows  deficiency  of  HCl,  excess  of  the  organic 
acids,  mucus,  and  remnants  of  undigested  food.  Yeast  may  be 
present. 

Acute  gastritis  may  complicate  and  mask  a  number  of  other 
gastrointestinal  and  systemic  diseases.  Care  should  be  taken  to 
differentiate  from  general  infections,  gall-stone  attacks,  peritonitis, 
appendicitis,  gastric  crises  of  tabes  dorsalis,  pregnancy,  early  stages 
of  ileus,  and  ulcer  in  dependent  area  of  stomach  in  ptosis.  The 
X-ray  is  often  necessary  for  diagnosis. 

Physical  Examination.  The  spinal  and  costal  lesions  are  as 
varied  as  are  the  cases,  including  entire  spinal  column  flat  and 
abnormally  rigid ;  slight  double  curves  crossing  at  the  sixth  dorsal 
and  involving  the  whole  spinal  column ;  a  rotation  of  the  fourth 
to  eighth  dorsal  with  spines  to  the  left ;  depression  of  the  ribs 
from  the  fifth  to  tenth;  various  combinations  of  lesions. 

"Contractions,  coupled  with  soreness  of  the  spinal  muscles  between  fourth 
and  eighth  dorsal  is  almost  a  positive  sign  of  dyspepsia  in  some  form.  Perhaps 
the  most  common  vertebral  lesion  is  a  right  lateral  condition  of  one  or  more 
vertebrae  between  the  fourth  and  eighth  dorsal,  though  an  anterior  condition 
of  one  or  more  vertebrae  in  this  region  is  a  very  common  finding,  and  in 
about  nine-tenths  of  the  cases  is  due  to  a  posterior  lumbar.  Rib  lesions  also 
are  very  common.  A  twisting  or  dropping  down  in  the  mid-axillary  line  of 
the  fifth  to  eighth  left  ribs  is  often  found  in  dyspepsia.  This  lesion  may 
be  independent  of,  or  due  to,  spinal  lesion.  Other  bony  lesions  affecting  the 
digestion  directly  or  reflexly  may  be  found  from  the  occiput  to  the  coccyx." 

— F.   Hudson. 

Treatment.  The  correction  of  whatever  irregularities  are  found 
in  the  structural  relations  is  the  most  important  factor  and  the 
treatments  should  be  continued  until  the  lesions  are  corrected  and 
the  hypersensitive  areas  are  gone.  The  patient  should  be  advised 
to  keep  as  quiet  as  possible,  although  rest  in  bed  is  not  imperative. 

Diet.  Until  the  symptoms  have  disappeared,  no  food  should  be 
allowed.  Cool  water  may  be  given  freely ;  hot  water  is  given  if  the 
hunger  is  annoying.  A  little  lemon  juice  or  grape  juice  may  be 
permitted  when  the  patient  finds  the  water  alone  distasteful.  The 
abdomen  should  be  palpated  in  all  cases,  and  when  fecal  matter  or 
accumulations  of  gas  are  recognized  the  colon  should  be  washed  in 
clear  w^ater  or  normal  salt  solution.  Copious  drinking  of  very  hot 
water  may  relieve  the  vomiting  and  secure  a  more  complete  removal 
of  the  offending  gastric  contents. 

Relief  can  sometimes  be  given  by  inhibition  in  the  suboc- 
cipital triangles,  or  over  the  course  of  the  vagus  in  the  neck ;  this 
sometimes  increases  the  nausea  and  should  then  be  discontinued, 
if  relief  does  not  become  evident  in  two  minutes  or  so.     Slow, 


40  THE  STOMACH 

steady  pressure,  gradually  increasing,  should  be  given  upon  the 
area  between  the  transverse  processes  of  the  fifth  to  the  seventh 
thoracic  vertebrae.  An  ice  bag  over  the  pit  of  the  stomach  or  over 
the  spinal  column  in  the  mid-thoracic  region  gives  relief.  Flatu- 
lency may  be  a  very  distressing  symptom.  Quick  movements, 
increasing  the  flexibility  of  the  entire  lower  thoracic  spinal  column, 
raises  the  blood  pressure  and  facilitates  the  absorption  of  the  gas. 
A  hot  water  bottle  may  exert  soothing  and  comfortable  warm  pres- 
sure over  the  pit  of  the  stomach.  Patients  with  gas  in  the  stom- 
ach, at  any  time,  should  be  carefully  watched  to  prevent  air-swal- 
lowing. This  act,  which  seems  to  be  almost  instinctive,  adds  to 
the  misery  and  prolongs  the  attack. 

When  toxic  substances  are  present  in  the  food  taken  or  as  the  result  of  fer- 
mentative or  putrefactive  process,  and  are  absorbed  into  the  blood  stream  rap- 
idly, the  effect  upon  the  system  may  be  profoundly  depressing.  The  phenomena 
usually  associated  with  surgical  collapse  may  be  present.  The  treatment  must 
be  energetic  and  careful  if  the  most  rdpid  recovery  is  to  be  secured.  The 
drinking  of  quantities  of  hot  water  is  useful  in  promoting  the  elimination  of 
the  toxins  from  the  body.  Very  free  colonic  irrigation  serves  the  same  pur- 
pose. The  rather  heavy,  energetic  treatment  which  increases  the  mobility  of 
the  spinal  and  costal  articulations  is  also  efficient.  The  ribs  should  be  well 
raised.  Care  should  be  taken  to  avoid  reflex  muscular  contractions,  especially 
in  the  suboccipital  and  cervical  areas. 

Prognosis.  In  mild  cases,  the  duration  is  from  a  few  days  to  a 
week,  terminating  in  recovery,  although  the  strength  may  not  be 
restored  for  some  time.  In  the  severer  cases,  the  acute  symptoms 
usually  subside  in  from  a  day  to  four  days  under  osteopathic  treat- 
ment, and  complete  recovery  may  be  expected  within  a  week  or 
two.  The  prognosis  in  the  toxic  form  is  very  grave ;  many  perish 
from  the  shock ;  others,  later,  from  exhaustion  and  starvation  inci- 
dent to  the  destructive  changes.  Those  who  recover  are  nearly 
always  affected  with  chronic  gastric  disturbances. 

Sequelae.  Each  acute  attack  predisposes  to  later  attacks,  and  the 
condition  of  chronic  inflammation  may  ensue.  The  reflex  muscular 
contractions  may  be  responsible  for  abnormal  spinal  and  costal 
structural  states,  which  also  increase  the  danger  of  subsequent 
attacks,  and  of  the  chronic  state  of  inflammation. 

ACUTE  PHLEGMONOUS  GASTRITIS  (abscess  of  the  stomach). 
This  is  a  rare  condition,  in  which  pyogenic  bacteria  inyade  the  walls  of  the 
stomach,  forming  localized  abscesses,  or  burrowing  between  the  layers  of  the 
stomach  walls.  Practically  the  entire  gastric  wall  may  become  converted  into 
masses  of  pus,  divided  by  strips  and  layers  of  the  original  tissues,  now  infil- 
trated and  degenerated. 

The  diagnosis  rests  upon  the  high  fever,  severe  pain,  chills,  and  other 
symptoms  of  pyogenic  invasion.  Leucocytosis  is  present,  and  may  help  in 
diagnosis  in  doubtful  cases.     The  vomiting  of  pus  makes  the  diagnosis  clear. 

It  seems  probable  that  small  abscesses  may  drain  spontaneously  into  the 
stomach,  and  recovery  may  occur.  The  burrowing  type  probably  is  invariably 
fatal.  When  the  abscess  is  localized,  surgery  may  help,  though  the  prognosis 
is  bad  under  all  circumstances. 


CHRONIC  GASTRITIS  41 

CHRONIC  GASTRITIS 

(Chronic  catarrh  of  the  stomach;   chronic  dyspepsia;  drunkard's   dyspepsia) 

Chronic  gastritis  is  a  chronic  inflammatory  disease  of  the  stom- 
ach, characterized  by  increased  secretion  of  mucus,  usually  dimin- 
ished gastric  juice  and  degenerative  changes  in  mucosa  and  mus- 
cularis. 

Etiology.  The  causes  of  the  disease  are  numerous,  as  is  to  be 
expected  from  its  functional  and  structural  relationships.  It  is  more 
often  found  in  men  than  in  women,  as  is  evident  from  the  list  of 
causes  of  the  disease.  Repeated  acute  attacks  of  gastritis  may 
result  in  chronic  inflammation.  Both  primary  and  secondary  forms 
of  the  disease  are  recognized,  in  both  of  which  the  bony  lesion  is 
variably  important  in  etiology.  Primary  chronic  gastritis  may  re- 
sult from  irregular  or  hasty  eating,  worry  or  other  emotional  dis- 
turbances, especially  at  mealtime,  and  constant  dietetic  errors, 
which  include  too  great  proportions  of  fat  and  of  carbohydrates; 
too  much  tea,  coffee,  alcohol  or  ice  water,  or  the  multitude  of 
soda-fountain  drinks;  insufficient  chewing;  highly  spiced  and  highly 
salted  foods;  the  use  of  tobacco,  and  other  bad  habits.  The  sec- 
ondary form  is  due  to  other  pre-existing  disease,  as  syphilis,  ne- 
phritis, gout,  anemia,  chlorosis,  diabetes,  and  others ;  local  causes, 
cancer,  ulcer,  etc. ;  disturbances  of  the  portal  circulation,  with  or 
without  cardiac  disease  or  cirrhosis.  Swallowing  infected  sputum 
or  saliva,  as  in  pulmonary  tuberculosis,  pyorrhea  alveolaris,  etc., 
may  be  responsible  for  the  inflammation.  Tight  lacing  is  not  now 
a  common  cause. 

The  most  important  bony  lesions  are  those  of  the  fourth  to  the 
ninth  vertebras  and  the  corresponding  ribs,  lesions  of  the  cervical 
region  and  of  the  first  and  second  ribs  and  the  clavicles.  These  act, 
probably  through  the  related  nerve  centers,  upon  the  stomach, 
affecting  its  secretions,  muscular  movements,  nutrition,  and  circu- 
lation. 

Pathology.  Three  states  of  chronic  gastritis  are  usually  considered 
in  dealing  with  its  pathology.  These  are  probably  to  a  great  extent  different 
stages  in  the  same  process,  though  it  seems  that  in  some  individuals  the  picture 
is  typical  of  one  or  another  form  from  beginning  to  the  end.  The  simplest 
and  most  tractable  and  probably  the  earliest  pathological  change  in  chronic 
gastritis  is  that  which  is  best  characterized  by  the  expression,  "simple  catarrhal." 
In  this  "type  an  increased  amount  of  mucin  is  secreted.  This  is  mixed  with  the 
food  which  is  taken,  and  may  be  vomited  or  may  pass  on  into  the  intestine  and 
be  digested.  It  forms  a  thick,  more  or  less  tenacious,  membrane  upon  the 
surface  of  the  gastric  mucosa.  This  protects  the  mucous  membrane  from  the 
stimulating  influence  of  the  food  which  is  taken  and  also  is  itself  an  irritation 
to  the  underlying  mucosa,  preventing  secretion  and  delaying  muscular  action. - 
The  mucous  membrane  may  be  grayish  in  color  and  usually  shows  small  hemor- 
rhagic areas,  especially  near  the  pylorus.  The  granular  elements  show  various 
stages  of  mucous  and  fatty  degeneration ;  erosion  may  occur  in  patches.  Pro- 
liferation of  the  mucous  glands  is  abundant.     The  mucosa  may  be  thickened. 


42  THE  STOMACH. 

or  may  be  thinned,  through  degeneration  and  erosion.  The  overgrowth  of  the 
sub-mucous  connective  tissue,  with  or  without  its  subsequent  contraction,  throws 
the  mucous  membrane  itself  into  irregular  folds  and  ridges.  Atypical  branch- 
ing of  the  tubules  is  frequently  noticed. 

Hypertrophic  Gastritis,  sclerosis  of  the  stomach  or  cirrhosis  ven- 
triculi,  is  characterized  by  the  presence  of  the  changes  in  the  mucous  mem- 
brane already  described,  to  which  is  added  considerable  overgrowth  of  the 
muscular  and  connective  tissue  walls  of  the  stomach.  The  walls  may  become 
so  thick  and  the  contraction  of  the  newly-formed  connective  tissue  so  profound, 
that  the  lumen  of  the  stomach  is  greatly  diminished.  This  hypertrophy  is 
usually  most  marked  around  the  pyloric  orifice,  thus  giving  rise  to  the  condi- 
tion called  hypertrophic  stenosis.  This  intense  multiplication  of  the  muscular 
and  connective  tissues  lessens  the  elasticity  of  the  mucous  layer  of  the  stomach, 
interferes  with  the  circulation  of  the  blood,  and  probably  exerts  more  or  less 
of  a  pressure  effect  upon  the  nerve  plexus  and  nerve  endings.  As  the  result 
of  this,  the  atrophy  of  the  glandular  elements  is  almost  certain  to  occur. 

Atrophic  Gastritis,  phthisis  ventriculi,  represents  the  terminal  stage 
of  chronic  gastritis.  The  atrophic  change  may  be  the  most  conspicuous 
feature  from  the  beginning,  or  it  may  follow  the  pathological  steps  which  have 
just  been  enumerated.  The  surface  of  the  stomach  is  smooth,  glistening,  gray- 
ish, like  a  thin  sheet  of  connective  tissue.  Here  and  there  small  areas  made 
up  of  remnants  of  the  gastric  mucosa  may  be  discerned.  Pigmented  areas,  the 
result  of  old  hemorrhages,  may  be  found,  ^n  the  muscular  wall,'  ridges  of  the 
hypertrophied  muscle  and  connective  tissue  may  remain;  especially  around  the 
pyloric  region  considerable  thickening  may  be  present.  But  generally  speaking, 
the  stomach  is  left  in  the  form  of  a  thin,  smooth,  dry,  inelastic  bag  which 
forms  no  secretion,  originates  no  sensory  impulses,  nor  is  capable  of  reacting 
to  any  nervous  stimulation. 

Diagnosis.  In  the  simple  catarrhal  form  the  symptoms  are  most 
varied.  The  appetite  is  capricious,  there  is  little  thirst,  but  the 
patient  craves  much  fluid  with  his  meals.  After  eating  there  is 
epigastric  distress,  oppression,  sense  of  fullness,  pyrosis  occasion- 
ally, pain  varying  at  different  times,  and  these  signs  are  associated 
with  tenderness.  The  frequent  eructations  of  gas  may  be  foul  or 
odorless,  there  is  belching,  and  well-marked  tympanitic  distention 
of  the  abdomen.  Vomiting,  preceded  by  nausea,  is  rather  frequent 
but  irregular,  the  most  characteristic  being  that  in  which  the  mucus 
is  vomited  in  the  morning  on  arising.  Constipation  is  usually  pres- 
ent but  may  alternate  with  diarrhea. 

The  tongue  shows  swollen  papillae,  indented  margins,  red  at  its 
tip  and  edges.  A  bad  taste  of  a  dry,  pasty,  or  salty  character, 
especially  in  the  morning  on  arising,  and  salivation  often  occurs. 
Palpitation  of  the  heart  is  not  uncommon.  The  "stomach  cough"  is 
due  to  a  chronic  pharyngitis  which  is  often  present.  The  nervous 
symptoms  include  headache,  vertigo,  disturbed  or  dreaming  sleep, 
depression  of  spirits,  yawning,  drowsiness  and  a  feeling  of  languor. 
In  late  stages,  especially  in  the  atrophic  form,  the  symptoms  and 
blood  count  may  simulate  pernicious  anemia. 

The  spinal  region  is  hypersensitive,  especially  just  before  an 
exacerbation.     The  subluxations  include  rotations  anywhere  from 


CHRONIC  GASTRITIS  43 

the  third  to  ninth  dorsal  vertebrae ;  flat  spine,  with  any  sort  of  indi- 
vidual lesions ;  double  curves,  crossing  between  the  fifth  and  sev- 
enth dorsal ;  elevated  or  depressed  ribs,  corresponding  to  the  ver- 
tebral lesions  or  sometimes  a  general  dropping;  more  rarely,  lesions 
of  the  first  to  third,  or  around  the  seventh  cervical  vertebrae  affect- 
ing the  vagi.    Spinal  rigidity  is  marked  in  all  cases. 

The  urine  is  usually  highly  colored  with  a  heavy  deposit  of 
urates,  and  calcium  oxalate  crystals  are  found. 

The  blood  shows  poor  nutrition  and  frequently  the  eosinophiles 
are  increased. 

In  Simple  Gastritis,  after  Ewald's  test  meal,  the  HCl  is  dimin- 
ished or  absent,  lactic  and  acetic  acids  are  found,  pepsin  and  rennin 
always  present  and  an  excess  of  mucus  mixed  with  the  food  rem- 
nants. The  fasting  stomach  contains  a  little  slimy  mucus  and 
sometimes  cells  from  the  glands.  Roentgenological  examination  is' 
of  value. 

In  Hypertrophic  Gastritis,  after  the  Ewald  meal,  HCl,  pepsin 
and  rennin  are  absent.  The  fasting  stomach  is  empty.  The  motor 
function  of  the  stomach  may  not  be  much  disturbed  or  there  may 
be  hypermotility. 

Treatment.  Persistent  and  continued  treatment  to  secure  cor- 
rection of  any  irregularities  of  the  spinal  or  rib  structures,  and 
securing  increased  mobility  of  each  articulation  is  essential. 

Diet.  Correction  of  the  diet  is  absolutely  necessary.  Increased 
drinking  of  water,  either  hot  or  cold,  is  usually  necessary.  Regular 
meals  of  well-cooked,  well-balanced  food,  thoroughly  masticated, 
with  such  variations  as  the  case  demands,  will  materially  assist 
recovery.  A -single  article  of  food  at  each  meal  is  sometimes  well 
digested.  The  bowels  must  receive  careful  attention.  Corrective 
and  systematic  exercises  may  be  necessary  to  tone  up  the  abdom- 
inal musculature.  Washing  out  the  stomach  is  sometimes  neces- 
sary when  vomiting  persists  or  when  there  is  much  mucus.  Drink- 
ing a  half  to  a  pint  of  hot  water  from  a  half  to  an  hour  before  meals 
and  especially  before  breakfast  may  be  a  substitute  for  the  usual 
method  of  washing.    Teeth  and  tonsils  should  receive  attention. 

Prognosis.  If  the  condition  is  secondary  the  recovery  depends 
upon  the  curability  of  the  primary  disease.  In  primary  cases  of  the 
catarrhal  forms  recovery  may  be  expected  only  in  patients  willing 
to  cooperate  in  following  out  all  dietetic  and  hygienic  advice  and 
having  treatment  regularly.  Supervision  with  treatment  as  indi- 
cated should  be  continued  for  at  least  six  months. 

In  the  hypertrophic  form  a  symptomatic  recovery  is  possible. 
In  the  atrophic  form  a  comfortable  life  depends  upon  the  mainte- 
nance of  hygienic  conditions. 


44  THE  STOMACH 

GASTRIC  AND  DUODENAL  ULCER 

(Perforating  ulcer;  peptic  ulcer) 

Peptic  ulcer  is  a  gradually  destroying  lesion  of  the  stomach  or 
the  duodenum,  never  below  the  bile  papillae  (that  is,  in  parts  not 
exposed  to  the  gastric  juice).  The  ulcer  is  usually  single.  Rarely, 
two,  or  even  several,  may  occur  at  the  same  time  or  in  succession. 

Etiology.  The  predisposing  causes  are:  age,  young  women 
from  15  to  30  years,  men  toward  middle  life  (recent  surgical  statis- 
tics increase  the  percentages  of  men)  ;  extensive  superficial  burns ; 
overwork;  poor  food;  anemia;  chlorosis;  lesions  of  the  spine  in  the 
splanchnic  area;  (the  sixth  thoracic  especially);  disturbed  circula- 
tion from  any  cause. 

The  ipimediate  factors  are  not  well  understood,  but  include  dis- 
turbed circulation  and  erosion  of  these  areas  through  the  digestive 
action  of  the  gastric  juice.  Disturbed  motility  (spasm  of  the  mus- 
cularis  mucosae)  deranged  innervation,  circulatory  involvement  and 
infections  and  toxins  are  perhaps  all  possible  factors  in  the  patho- 
genesis. 

Site.  The  solitary  ulcer  is  most  frequently  found  on  the  pos- 
terior wall  near  to,  or  involving,  the  lesser  curvature  and  in  the 
neighborhood  of  the  pylorus.  Acute  ulcers  may  be  found  in  the 
middle  region,  or  at  the  cardiac  end,  but  the  cardiac  orifice  is  rarely 
implicated.  Ulcers  may  sometimes  be  situated  upon  the  anterior 
wall  and  are  then  very  liable  to  perforate.  Duodenal  ulcers  are 
now  known  to  be  much  more  frequently  present  than  was  formerly 
supposed. 

Pathology.  The  acute  form  is  small,  sharply  punched  out,  and  the 
edges  are  clear  cut  and  soft,  the  floor  smooth  and  the  serous  coat  not  thickened. 

The  chronic  form,  the  typical  ulcer,  is  round  or  oval,  extending  more  or 
less  into  the  wall  of  the  viscus ;  has  a  characteristic  funnel  shape,  the  edges 
being  terraced,  more  or  less  sharply  cut,  and  gradually  narrowing  to  the  base. 
In  very  chronic  cases,  the  edges  may  be  rounded  and  the  whole  wall  thickened 
with  marked  vascularity  in  the  margins  and  base. 

The  floor  is  formed  by  ,the  submucosa,  the  muscular  coat  or  the  serous 
coat,  which  may  be  thickened  and  adherent  to  other  organs. 

In  healing,  if  the  mucosa  is  alone  involved,  a  smooth  scar  is  left;  but  if 
the  deeper  structures  were  involved,  cicatricial  contraction  may  cause  serious 
changes,  a  narrowing  of  the  pyloric  orifice,  dilatation  of  the  stomach  or  hour- 
glass contraction. 

Perforation  may  occur  with  subsequent  peritonitis;  adhesions  may  form 
between  the  walls  of  the  stomach  and  other  organs  so  that  the  ulcer  may 
burrow  into  them ;  gastro-duodenal  fistula  may  form ;  perforation  may  occur 
into  the  pleura,  or  into  the  lesser  peritoneum,  giving  rise  to  subphrenic  abscess. 

Hemorrhage  may  arise  from  the  erosion  of  a  large  blood  vessel.  Healing 
occurs  by  the  formation  of  scar  tissue. 

Diagnosis.  There  is  no  disease  or  condition  which  may  have 
such  characteristic  symptoms,  or  which  may  be  more  ill-defined. 
The  proportion  of  autopsies  in  which  ulcers  are  found  is  much 


ULCBR  45 

greater  than  would  be  expected  from  the  small  number  of  cases 
in  which  the  disease  is  recognized  ante  mortem. 

Pain  and  tenderness  over  the  epigastrium  are  constant.  The 
pain  is  rendered  worse  by  eating  or  by  firm  pressure,  when  the 
ulcer  is  located  near  the  cardiac  end  of  the  stomach,  but  is  re- 
lieved by  taking  food  or  drink  when  the  ulcer  is  near  the  pylorus 
or  in  the  duodenum.  This  pain  varies  with  the  location  of  the 
ulcer,  is  constant  and  well  defined,  and  is  accompanied  by  cutaneous 
sensitiveness  or  hyperalgesia  extending  further  to  the  left.  The 
upper  belly  of  the  left  rectus  muscle  is  frequently  contracted. 

The  reflex  area  of  spinal  hypersensitiveness  varies  slightly,  but 
is  usually  found  between  the  sixth  and  the  ninth  thoracic  spinous 
or  transverse  processes. 

Vomiting  may  occur  soon  after  eating  or  more  frequently  after 
an  hour  or  so,  and  usually  gives  relief. 

Hematemesis  may  be  slight  or  copious,  and  may  be  directly 
fatal.  Melaena,  or  passage  of  blood  by  the  bowel,  is  present  in  about 
ten  per  cent  of  cases. 

The  appetite  is  good  but  the  patient  may  be  afraid  to  eat,  lest 
pain  is  set  up.    The  tongue  is  clean  and  may  be  pale  and  flabby. 

The  vertebral  lesions  may  be  anywhere  in  the  splanchnic  area, 
but  those  from  the  fifth  to  the  ninth  seem  especially  frequent. 
There  may  be  lesions  of  the  cervical  region.  The  anterior  ends  of 
the  eighth  to  the  tenth  ribs  are  usually  subluxated. 

There  is  usually  found  a  circumscribed  tenderness,  or  a  tender 
spot,  to  the  left  of  the  eleventh  or  twelfth  dorsal  vertebrae.  In  old 
ulcers  a  distinct  induration  may  often  be  felt  near  the  pylorus. 
The  X-ray  gives  exact  information  in  a  surprisingly  large  number 
of  cases. 

The  Blood  shows  a  chloro-anemia  which  may  be  1,000,000  or 
less  per  cmm. 

Gastric  Analysis  shows  excess  of  free  HCl  (hyperchlorhydria). 
Increase  of  organic  acids  is  rare,  but  may  be  present  in  old  stand- 
ing cases  with  dilatation.  The  stomach  tube  must  be  used  with 
care.  Blood  is  frequently  found ;  sometimes  there  may  be  shreds 
of  tissue  or  isolated  cells  from  the  edges  of  the  ulcer.  •  When  the 
condition  is  coexistent  with  cancer,  as  often  occurs,  the  vomitus 
presents  very  contradictory  findings. 

Duodenal  Ulcer.  Three  symptoms  form  an  almost  pathognom- 
onic picture;  "hunger  pain,"  pain  coming  on  two  to  four  hours 
after  food  and  often  at  night,  relieved  by  food,  and  situated  in  the 
right  hypochondrium ;  tenderness  in  the  right  hypochondrium  with 
rigidity  of  the  right  rectus  muscle ;  repeated  attacks  of  melaena,  not 
accompanied  by  hematemesis,  the  stools  being  dark  and  tarry; 
history  of  digestive  disturbances. 


46  THE  STOMACH 

Treatment.  Structural  corrective  work  must  be  done  until 
the  spine  and  its  associated  structures  are  in  normal  adjustment, 
paying  particular  attention  to  the  area  of  the  sixth  dorsal.  The 
pain  may  be  lessened  by  deep  steady  pressure  through  the  splanch- 
nic area.  The  vomiting  is  best  relieved  by  thorough  relaxation 
followed  by  deep  steady  pressure  in  the  region  of  the  fourth  and 
fifth  dorsals  on  the  right  side.  Be  specially  careful  in  giving  direct 
treatment  or  in  palpating  over  the  abdomen.  Absolute  rest  in  bed 
must  be  insisted  upon  for  at  least  a  month. 

The  diet  at  first  should  be  very  restricted.  Rectal  feeding,  or 
none,  should  be  given  for  a  few  days,  in  moderately  severe  attacks. 
Small  amounts  of  very  bland,  easily  digested,  and  moderately  warm 
food  may  then  be  given  at  stated  intervals.  It  may  consist  of  milk 
or  buttermilk  or  milk-gruel,  of  wheat  flour  or  arrowroot,  or  if  milk 
is  not  well  borne,  of  egg  albumen,  or  Leube's  beef  solution.  "Milk 
surely  has  a  specific  action  on  the  disease  when  hyperchlorhydria 
is  present,  as  it  usually  is.  The  excessive  quantity  of  acid  is  all 
used  up  in  the  digestion  of  the  milk,  so  being  removed  from  con- 
tact with  the  stomach  walls  in  this  physiological  way,  it  is  power- 
less to  increase  or  perpetuate  the  trouble." — R.  F.  Weeks. 

Lavage  is  useful  when  there  is  a  complicating  catarrhal  gas- 
tritis, or  for  the  removal  of  improper  foods. 

In  active  hemorrhage,  ice  bags  over  the  abdomen,  rectal  feeding, 
and  later  hypodermoclysis  may  be  used  according  to  the  case. 
Surgical  interference  is  indicated  in  a  chronic  indurated  ulcer;  in 
mechanical  interference  with  the  passage  of  the  gastric  contents;  in 
recurring  hemorrhage;  in  perforation,  very  rpeedily. 

Prognosis.  Guardedly  favorable,  depending  upon  the  patient, 
the  severity  of  the  symptoms,  and  the  duration.  Complications 
include  hemorrhage  and  perforation.  Sequelae  include  stenosis 
from  cicatrization.  The  relation  of  cancer  to  ulcer  must  not  be 
forgotten.  f 

CANCER  OF  THE  STOMACH 

By  far  the  most  important  of  all  the  neoplasms  of  the  stomach 
are  the  cancers.  Some  variation  is  noted  as  to  the  relative  fre- 
quency of  certain  types,  but  the  scirrhous  and  the  colloid  types 
occupy  first  place.  Squamous  epithelioma  is  occasionally  found 
near  the  cardiac  orifice ;  it  probably  originates  in  the  epithelium  of 
the  esophagus,  or  from  cells  which  belong  to  that  structure.  Sar- 
coma is  rare;  it  is  not  to  be  distinguished  from  carcinoma  except 
by  autopsy  or  surgery. 

Etiology.  The  true  causes  of  cancer  are  yet  unknown.  There 
seems  no  doubt  that  almost  any  constant  irritation  may  be  an 
important  factor.    In  some  individuals  inflammatory  reproduction 


CANCER  47 

of  cells  does  not  cease  at  a  reparative  stage,  but  continues  on  into 
the  formation  of  malign  growths.  In  acute  and  chronic  gastritis, 
gastric  ulcer,  and  trauma  due  to  swallowing  injurious  objects,  the- 
stomach  is  certainly  provided  with  sufficient  causes  of  irritation.  In 
its  embryonic  development  considerable  rearrangement  of  the  cell 
masses  is  necessary ;  from  the  standpoint  of  Cohnheim's  theory  it  is 
to  be  expected  that  gastric  cancers  should  be  relatively  frequent, 
one-half  of  all  cases.  There  is  considerable  evidence  in  favor  of 
the  view  that  an  inheritance  of  possible  cancer  follows  Mendel's 
law,  being  a  recessive  characteristic.  Cancer  is  everywhere  most 
frequent  in  late  middle  life  and  early  old  age.  Rarely  cases  are 
seen  in  children,  even  at  birth. 

Gastric  cancer  is  much  more  frequent  among  men  than  women. 

Later  statistics  indicate  constantly  more  closely  the  relationship 
between  gastric  ulcer  and  gastric  cancer — the  cancer  arising  from 
the  edge  of  the  ulcer.  When  the  cell-multiplication  characteristic 
of  gastric  ulcer  and  of  catarrhal  and  hypertrophic  gastritis  is  remem- 
bered, it  seems  surprising  that  this  relationship  has  not  long  been 
recognized.  Alcoholism  is  present  in  a  large  proportion  of  cancer 
cases.  The  place  of  tuberculosis,  worry,  and  direct  trauma  is  very 
uncertain. 

The  place  of  bony  lesions  in  the  etiology  of  cancer  is  still 
doubtful.  Since  these  seem  to  affect  the  vasomotor  control,  the 
secretory  activity,  and  the  muscular  activity,  it  would  seem,  a  priori, 
that  these  might  be  responsible,  at  least  indirectly,  for  the  irritation 
which  seems  one  factor  in  cancer  growth.  In  some  instances,  it 
seems  that  nervous  impulses  may  initiate  cell  reproduction,  and 
it  is  thus  possible  that  abnormal  nerve  impulses  may  be  responsible 
for  the  constant  and  unbridled  overgrowth;  or  it  may  be  that 
failure  of  the  normal  controlling  impulses  is  responsible  for  the 
continued  multiplication  of  the  cells. 

In  any  event,  the  maintenance  of  a  correct  circulation  and  inner- 
vation for  the  stomach  must  be  the  best  thing  for  resistance  to 
disease  and  for  recovery  from  injury. 

Site.  The  growth  may  be  situated  at  either  orifice  or  in  the 
wall,  the  pylorus  first  in  frequency,  then  the  lesser  curvature  and 
next  the  cardia.  The  carcinoma  may  infiltrate  all  the  coats  and 
invade  the  neighboring  organs,  the  dilated  lymphatic  vessels  of 
the  serous  coat  being  filled  with  the  carcinoma  cells.  The  retro- 
peritoneal, inguinal,  thoracic,  supraclavicular  lymph  glands  become 
involved.    Metastasis  may  take  place  through  the  blood  vessels. 

Diagnosis.  Early  diagnosis  is  difficult.  When  gastric  ulcer 
becomes  associated  with  diminished  hydrochloric  acid  or  its  total 
lack,  cancer  should  be  strongly  suspected.  When  men  or  women 
past  forty  become  subject  to  gastric  symptoms  for  which  no  ade- 
quate cause  can  be  found,  the  diagnosis  of  cancer  is  probable. 


48      ^  THE  STOMACH 

The  most  satisfactory  information  comes  from  the  study  of  a 
series  of  X-ray  plates.  Exploratory  laparotomy  may  be  indicated. 
The  general  symptoms  are,  loss  of  weight  and  strength ;  the  skin 
is  often  of  a  yellow  or  lemon  tint  which  with  the  emaciation  gives 
the  cachectic  appearance;  mild  fever;  indicanuria,  edema,  especi- 
ally of  the  ankles,  and  constipation  or  diarrhea. 

The  functional  symptoms  include  anorexia  and  nausea,  though 
the  appetite  may  remain  good.  Vomiting  may  occur  early  or  late, 
varying  with  the  case,  and  being  more  frequent  when  the  orifices 
are  involved.  Hemorrhage  in  some  cases  is  the  first  symptom.  It 
is  rarely  profuse.  Usually  there  is  a  slight  oozing  which  when 
mixed  with  the  stomach  secretions  produces  the  "coflfee-ground" 
appearance  of  the  vomitus.  Pain  is  variable,  most  commonly  in 
the  epigastrium,  and  may  be  of  a  burning,  dragging,  gnawing  char- 
acter. It  is  not  much  relieved  by  vomiting;  is  aggravated  by  taking 
food,  and  is  accompanied  by  marked  tenderness  of  the  epigastrium 
on  pressure.  It  is  most  marked  between  the  nipple  line  and  the 
umbilicus  in  front,  and  between  the  fifth  and  twelfth  ribs  in  the 
back.  Lesions  may  be  found  anywhere  from  the  fourth  to  the  ninth 
dorsal  vertebrae  and  in  the  corresponding  ribs.  These  seem  to  be 
due  to  reflex  muscular  contractions.  The  ribs  in  general  may  be 
much  depressed;  neck  lesions  may  be  found.  Bony  and  muscular 
lesions  are  probably  secondary. 

The  tumor  may  be  felt,  is  motile,  changing  with  respiration,  and 
is  painful  on  palpation.  The  percussion  note  over  the  tumor  is 
often  flat. 

The  urine  may  be  unchanged;  it  usually  contains  increased 
indican.  An  anemia  simulating  the  primary  pernicious  type  is 
sometimes  present.  The  red  cell  count  is  always  low,  sometimes 
dropping  progressively  until  death ;  the  color  index  is  usually  below 
normal ;  nucleated  reds  are  rare,  and  a  leucocytosis  is  present,  but 
varies  greatly.    Atypical  cells  are  abundant. 

Gastric  analysis.  The  danger  of  perforation  by  a  stomach  tube 
in  the  hands  of  any  but  an  expert — perhaps,  even  then — must  not 
be  forgotten.  The  vomitus  and  the  washings  should  be  examined 
frequently  in  suspected  cases. 

Probably  the  most  important  finding  is  the  diminished  or  lack- 
ing hydrochloric  acid.  This  condition  may  be  present  also  in 
atrophic  and  in  nervous  gastritis,  in  carcinoma  of  the  duodenum 
or  pancreas,  in  pernicious  anemia,  and  in  other  more  easily  recog- 
nized conditions.  It  is  also  true  that  there  may  be  increased  hydro- 
chloric under  certain  circumstances,  with  cancer;  as,  for  example, 
when  a  cancer  arises  from  the  edge  of  an  ulcer.  The  low  hydro- 
chloric seems  to  be  due  to  the  presence  of  some  combining  agent, 
probably  from  the  cancer  cells  themselves.  Lactic-acid  is  present 
only  when  there  is  a  deficiency  of  hydrochloric.     The  growth  of 


DILATATION  ~  49 

the  Oppler-Boas  bacillus  occurs  only  in  the  presence  of  lactic  and 
the  absence  of  hydrochloric  acid.  This  gives  it  place  in  diagnosis. 
Blood  and  pus  are  fairly  constant  findings.  Often  the  examina- 
tion of  centrifugalized  washings  will  show  some  of  the  cancer  cells. 
These  may  be  found  in  shreds  large  enough  for  frozen  or  paraffin 
section,  and  the  diagnosis  can  then  be  made  with  accuracy.  More 
often  the  cells  are  found  in  small  groups;  if  these  show  irregular 
karyokinetic  figures  the  diagnosis  of  malignant  neoplasm  is  justi- 
fied. 

Complications.  Secondary  growths  are  common,  especially  of 
the  liver  and  the  lymph  glands,  especially  one  at  the  posterior 
border  of  the  sterno-mastoid  muscle.  Perforation  may  cause  sud- 
den death. 

Treatment.  Early  diagnosis  is  difficult  and  very  important. 
Early  surgical  treatment  offers  the  best  hope  of  recovery.  Pallia- 
tive treatment  is  necessary  in  most  cases.  A  good  deal  of  the  pain 
may  be  relieved  by  careful  spinal  treatment  using  such  measures 
as  are  indicated  in  the  particular  case. 

A  milk  diet  or  milk  with  other  easily  digested  foods  is  advisable. 
Lavage  may  be  necessary  to  control  vomiting  and  excessive  fer- 
mentation. The  bowels  must  be  kept  normal.  Enemas  and  rectal 
feeding  are  useful. 

The  pain  can  be  controlled  for  a  time  by  ice  bags,  etc.  When 
the  diagnosis  of  inoperable  carcinoma,  or  recurrent  carcinoma  has 
been  made,  the  patient  should  be  kept  comfortable  though  at  the 
expense  of  a  few  days  of  life.  So  the  use  of  cocaine,  opium,  and 
other  analgesics  is  fully  indicated.  Toward  the  last  it  is  some- 
times necessary  to  use  chloroform.  The  use  of  drugs  should  be 
postponed  until  the  hopelessness  of  the  case  is  evident. 

Prognosis.  Early  surgery  may  give  a  good  prognosis.  Other- 
wise death  is  to  be  expected  in  about  six  months  after  the  disease 
is  recognized.  The  scirrhous  type  presents  a  somewhat  slower 
progress  than  other  forms.' 

GASTRIC  DILATATION 

(Gastrectasis ;  pyloric  obstruction ;  pyloric  stenosis) 

Gastrectasis  is  an  abnormal  increase  in  the  size  of  the  cavity 
of  the  stomach  and  may  be  from  nonobstructive  or  obstructive 
causes.  The  normal  stomach  contracts  when  empty ;  a  relaxed 
stomach,  after  food  has  passed  from  it,  is  atonic;  it  may  be  dilated 
or  may  become  dilated  at  any  time. 

Etiology.  The  nonobstructive  causes  are  due  to  atony  of  the 
muscular  coat  whether  as  the  result  of  repeated  overdistention 
with  food,  of  constitutional  diseases,  as  anemia,  acute  fevers  or 


so  rnn  stomach 

chronic  gastritis,  or  of  defective  innervation  from  lesions  in  the 
splanchnic  region,  general  weakness  from  flat,  ragged,  rigid 
spines  or  those  with  curvatures.  The  rigid  spine,  with  slight 
posterior  curve,  involving  the  tenth  thoracic  to  the  second  lumbar 
vertebrae,  is  a  very  frequent  etiological  factor. 

Obstructive  dilatation  is  caused  by  stenosis  of  the  pylorus  from 
cicatrizing  ulcer  or  from  cancer;  by  pressure  of  the  duodenum  or 
contracture  after  duodenal  ulcer;  abdominal  tumors;  by  contrac- 
tion of  pylorus ;  by  adhesions  in  chronic  gastritis. 

In  acute  dilatation  the  predisposing  factors  are  operation  under 
general  anaesthesia ;  severe  and  prolonged  disease ;  indiscretions  in 
diet;  disease  or  deformity  of  the  spine;  traumatism.  Direct 
causes  are  primary  paresis  of  the  gastric  musculature,  or  obstruc- 
tion to  the  onward  flow  of  the  gastric  contents,  especially  to 
obstructions  just  below  the  bile  papillae  of  the  duodenum,  or  at 
the  point  where  the  duodenum  passes  beneath  the  insertion  of  the 
mesentery. 

Diagnosis.  The  symptoms  occur  at  irregular  intervals ;  pain  may 
be  several  hours  after  eating;  at  the  end  of  the  day;  or  several  days 
may  intervene  between  attacks.  There  is  diffuse  burning  epigas- 
tric pain  relieved  by  vomiting  which  the  patients  often  excite. 
The  pain  is  most  marked  at  night.  Flatulence  and  constipation 
are  common.  The  tongue  is  pale  and  furred,  or  red,  smooth  and 
shiny;  or  soft  and  flabby.  There  is  loss  of  strength  and  flesh  and 
the  respiration  and  circulation  are  both  affected.  The  patient 
is  irritable,  depressed,  more  or  less  melancholy  and  subject  to 
vertigo. 

In  acute  paralytic  distention  due  to  blows  or  operations  upon 
the  abdomen,  the  symptoms  appear  suddenly,  the  surrounding 
organs  are  interfered  with,  and  collapse  follows.  At  first  there 
is  some  belching  but  the  patient  is  soon  unable  to  move  the  gas 
and  sufl"ers  extreme  discomfort,  palpitation,  and  dyspnea.  Vomit- 
ing is  persistent  and  excessive,  occurring  at  once  or  later.  There 
are  the  same  physical  signs  as  in  the  chronic  form. 

The  spine  may  be  ragged,  rigid,  or  flat  or  have  slight  curves. 
Individual  lesions  may  be  found  anywhere  in  the  splanchnic  region. 
Less  often  lesions  of  the  upper  thoracic  are  found ;  sometimes 
lesions  of  the  cervical  vertebrae.  When  the  central  connections  of 
the  vagal  and  the  splanchnic  centers  are  remembered,  it  is  evident 
that  the  lesions  affecting  gastric  innervation  may  be  very  widely 
distributed. 

When  dilatation  is  marked,  there  may  be  seen  abnormal  prom- 
inence of  the  whole  epigastric  region.  The  outline  of  the  greater 
curvature  and  sometimes  the  lesser  may  be  visib^e.  By  forcibly 
stroking  the  epigastrium,  peristaltic  movements  of  the  stomach 


DILATATION  SI 

may  be  set  up.  In  the  atonic  form,  there  is  absence  of  peristaltic 
waves.    A  pyloric  tumor  may  sometimes  be  felt  on  palpation. 

The  actual  size  of  the  stomach  may  be  determined  by  artificial 
distention  with  fluid  or  gas,  the  greater  curvature  can  then  be 
percussed  out.  Succussion  or  clapotage  can  be  heard  at  a  time 
when  the  stomach  should  be  empty. 

By  the  passage  of  a  hard  sound,  the  depth  can  be  determined. 
If  over  sixty  centimeters  from  the  mouth,  there  is  some  degree 
of  dilatation. 

The  use  of  the  bismuth  meal  and  the  X-ray  will  determine  the 
size,  activity  and  position  of  the  stomach. 

Gastric  Analysis.  The  vomitus  is  larger  in  quantity  than  nor- 
mal ;  is  excessively  sour,  early  due  to  excess  of  HCl  and  later  to 
lack  of  HCl  and  an  excess  of  organic  acids;  contains  fragments 
of  partially  digested  food,  and  microscopically  shows  the  presence 
of  the  bacillus  acidi  lactici,  bacillus  butyricus,  and  the  sarcina  ven- 
triculi.  On  standing,  the  stomach  contents  separate  into  three 
layers;  the  upper,  frothy  and  containing  mucus  and  fermenting 
food ;  the  middle  layer,  clear  and  watery ;  the  lower,  finely  divided 
and  consisting  of  more  or  less  completely  digested  food.  In  great 
dilatation,  there  is  bacterial  fermentation  owing  to  the  delay  of 
the  stomach  contents. 

Treatment.  The  correction  of  the  spinal  and  rib  lesions  as 
found  as  well  as  the  correction  of  any  structural  perversions  that 
may  be  found  anywhere  in  the  body,  is  of  first  importance.  Direct 
manipulation  of  the  stomach  through  the  relaxed  abdominal  wall 
is  useful — this  initiates  contraction  of  the  gastric  muscle,  as  may 
be  seen  by  watching  the  abdomen.  The  patient  should  be  taught 
to  do  this  night  and  morning.  Thus  the  m.uscle  is  strengthened. 
Care  must  be  used  to  avoid  overfatigue.  In  the  corrective  treat- 
ment, the  brisk,  energetic  methods  should.be  chosen.  If  the  manip- 
ulation slightly  increases  the  blood  pressure,  it  is  probably  more 
efficient  than  if  the  blood  pressure  decreases  as  the  result  of  the 
treatment. 

Many  cases  present  a  picture  of  general  enteroptosis.  In  addi- 
tion to  the  abdominal  findings  there  is  a  stooped,  slumped  posture, 
round  shoulders,  ewe  neck,  depressed  lower  ribs,  etc.  Setting-up 
exercises,  drawing  the  abdomen  up  and  in,  while  at  the  same  time 
slowly  forcing  respiration  in  order  to  develop  the  muscles  thus 
used  will,  if  persisted  in,  prove  of  great  benefit.  Then  treatment 
of  the  viscera  in  the  knee-chest  position  is  of  added  value. 

If  it  is  possible  to  put  the  patient  to  bed.-w^ith  quiet  and  com- 
fortable surroundings,  good  nursing,  and  treatment  every  day, 
his  recovery  will  be  much  more  rapid.  This  should  be  continued 
until  some  diminution  in  the  size  of  the  organ  occurs ;  he  is  then 
allowed  to  be  up,  to  have  a  little  more  liberty  in  diet,  and  to  have 


52  THE  STOMACH 

the  treatments  at  intervals  of  two,  three,  and  finally,  seven  or 
fourteen  days.  He  must  return  for  examination  at  intervals  for 
two  years  or  more,  if  he  is  to  avoid  a  recurrence  of  the  trouble. 

The  intestinal  condition  should  receive  the  attention  required 
in  each  individual  patient.  No  purgatives  should  be  permitted; 
enemas  may  be  used  if  necessary. 

Lavage  may  be  useful  in  removing  the  products  of  fermenta- 
tion, as  a  palliative  measure.  It  is  less  harmful  to  the  stomach 
than  the  retention  of  this  irritative  material,  but  will  not  long  be 
necessary,  if  the  correct  treatment  otherwise  is  given. 

Diet.  Only  small  amounts  of  food,  and  very  small  amounts  of 
water  or  other  liquids,  should  be  permitted  at  any  one  time;  the 
intervals  should  be  long  enough  to  allow  the  stomach  to  become 
empty.  Foods  which  ferment  are  to  be  denied ;  this  includes 
chiefly  the  sweets,  starches  and  fats.  Beet  is  the  favorite  food; 
this  is  usually  well  liked,  leads  to  increased  gastric  secretion  and 
activity,  and  gives  a  sense  of  well-being  that  is  comforting.  Broths 
in  small  amounts;  fruit  juices,  vegetable  juices  may  be  allowed  at 
long  intervals.  The  dry  diet  may  be  used;  this  is  simply  the 
giving  of  perfectly  dry  food,  which  must  be  chewed  a  long  time 
before  it  can  be  swallowed.  Very  small  amounts  of  food  thus 
satisfy  the  appetite,  and  the  nervous  effect  of  a  feeling  of  satiety 
is  good. 

An  abdominal  bandage  is  sometimes  of  benefit.  A  corset  which 
exerts  a  very  slight  pressure  upon  the  distended  organ,  and  which 
supports  it,  may  give  much  relief,  especially  to  patients  who  must 
be  on  their  feet  much  of  the  time. 

In  most  obstructive  cases  surgery  is  the  best  thing  that  can 
be  done.  Gastroenterostomy  or  gastro-plication  are  most  fre- 
quently needed.    Other  operations  may  be  required. 

In  certain  acute  dilatations,  if  conditions  permit,  actually  stand- 
ing the  patient  upon  his  head  for  a  few  moments  may  give  imme- 
diate and  distinct  relief.  (This  is,  no  doubt,  due  to  the.  relief  of 
the  duodenum  from  pressure  as  it  passes  beneath  the  insertion  of 
the  mesentery.) 

When  the  cause  of  the  obstruction  can  be  removed,  the  prog- 
nosis is  good  for  recovery ;  after  the  surgical  intervention,  the  treat- 
ment already  advised  should  be  instituted,  with  suitable  modifica- 
tions, according  to  individual  needs. 

Prognosis.  Depends  entirely  upon  the  causative  disease;  but 
the  treatment  will  require  months  rather  than  weeks  of  time,  in 
mild  cases. 

Atonic  cases  often  recover  completely  within  a  few  months.  If 
the  original  causes  of  the  disease,  indiscretions  in- food  or  drink, 
tight  lacing,  etc.,  are  again  permitted,  further  dilatation  is  to  be 


DILATATION  53 

expected.  If  the  spinal  conditions  are  permitted  to  recur,  the 
same  thing  is  probable.  Patients  who  have  once  suffered  from 
dilatation  may  undergo  exacerbations  as  the  result  of  suddenly- 
produced  bony  lesions,  strains  of  the  spinal  column,  or  extreme 
fatigue.  Too  long  continued  standing  is  provocative  of  recur- 
rences. Emotional  states,  especially  depressive,  are  apt  to  result 
in  relaxation  of  the  gastric,  as  well  as  of  other  visceral  muscles. 

In  obstructive  cases,  especially  those  due  to  post-ulcerative 
cicatrice,  marked  variations  in  the  condition  of  the  patient  may 
lead  to  unbased  cheerfulness  in  the  prognosis ;  this  is  to  be  avoided 
under  all  conditions.  After  surgical  relief,  of  obstructions,  recov- 
ery is  not  apt  to  be  uneventful,  though  the  treatment  as  indicated 
above  prevents  interruptions  in  convalescence  to  a  marked  extent. 
In  those  cases  in  which  the  obstruction  cannot  be  relieved,  con- 
siderable palliation  is  to  be  expected  as  the  result  of  the  treatment 
indicated. 

The  stomach  once  dilated  probably  is  always  more  liable  to 
dilatation  than  one  which  has  retained  its  tone ;  therefore,  the 
risk  of  later  attacks  should  teach  patients  to  avoid  very  carefully 
the  things  which  originally  caused,  or  which  might  cause,  the  gas- 
tric weakness  or  the  subsequent  distension. 


CHAPTER  V 
DISEASES  OF  THE  INTESTINES 

• 

The  nomenclature  of  the  diseases  of  the  intestines  is  so  con- 
fusing that  an  adequate  arrangement  is  difficult.  To  find  the 
same  disease  described  under  the  same  name  by  different  authors  is 
rare.  The  anatomical  arrangement  conforms  best  with  the  pathol- 
ogy but  in  some  instances  has  been  hard  to  follow.  To  classify 
according  to  symptomatology  does  not  seem  logical. 

THE  SYMPTOM  DIARRHEA 

Diarrhea  is  a  symptom  of  intestinal  inflammation  of  some  kind 
consisting  of  frequent  alvine  discharges,  the  character  of  which 
indicates  somewhat  the  seat  of  the  lesion. 

Lienteric  stools  contain  considerable  undigested  food  and  point 
to  inflammation  of  the  stomach  and  upper  bowel. 

Mucous  stools  are  those  in  which  a  large  quantity  of  mucus  is 
present  and  indicate  inflammation  in  the  lower  bowel. 

Watery  or  serous  stools  occur  in  nervous  and  colliquative 
diarrheas,  enteritis,  cholera,  and  similar  affections. 

Green  stools  are  due  to  an  excess  of  bile,  chlorophyll,  or  bacillus 
pyocyaneus. 

Fatty  stools  are  produced  by  the  ingestion  of  large  quantities 
of  fatty  foods,  by  pancreatic  diseases,  and  by  the  absence  of  bile. 

Purulent  stools  arise  from  ulcerations  along  the  intestinal  tract 
or  the  rupture  of  adjacent  abscesses  into  the  bowel. 

Black  stools  may  be  due  to  the  presence  of  blood  from  hem- 
orrhage high  up  in  the  bowel,  to  bismuth,  charcoal  or  tannate  of 
iron,  etc.,  taken  as  medicine,  or  berries  eatfen  freely. 

Red  stools  result  from  the  presence  of  fresh  blood,  or  the 
administration  of  medicine  containing  hematoxylin. 

Bloody  stools  (melana)  result  from  hemorrhage  from  any  por- 
tion of  the  digestive  tract  from  whatever  cause,  infective,  inflam- 
matory, or  traumatic. 

Parasites  or  their  eggs  may  be  found  in  the  stools. 

INTESTINAL  NEUROSES 

Two  classes  of  intestinal  neuroses  are  to  be  recognized — those 
due  to  organic  nervous  disease,  and  those  due  to  functional  dis- 

54 


INTESTINAL  NEUROSES  55 

turbance  of  the  nerve  centers.  The  second  class  is  of  etiological 
importance  in  almost  if  not  all  of  the  organic  intestinal  diseases, 
either  directly  (abnormal  innervation),  or  indirectly  (abnormal 
vasomotor  control,  abnormal  function  of  distant  organs — liver, 
heart,  etc.).  In  the  second  class  also  are  to  be  included  the  hysteric 
and  neurasthenic  states  and  neuralgias. 

The  neuroses  may  be  secretory,  motor,  or  sensory. 

The  sensory  disturbances  are  usually  associated  with  disturb- 
ances of  secretion  and  motion,  since  the  action  of  the  secretory, 
vasomotor  and  visceromotor  centers  depends  to  a  certain  extent 
upon  sensory  stimulation. 

Enteralgia  (Neuralgia  of  the  intestines)  is  most  often  found  in 
hysterical  patients;  it  may  occur  in  the  neurasthenic,  or  as  a  re- 
ferred irritation  from  pelvi6,  hepatic  or  renal  disease,  or  from  bony, 
lesions,  usually  of  the  innominates  or  sacrum.  The  attacks  most 
often  follow  great  fatigue  or  emotional  storms.  It  is  most  fre- 
quent in  poorly  nourished  patients.  (See  Neuralgia.)  Hypogastric 
neuralgia  is, the  term  sometimes  applied  to  enteralgia  located  around 
the  coccyx  or  the  perineum.  It  is  accompanied  by  an  irresist- 
ible desire  to  go  to  stool,  but  defecation  is  impossible.  The 
pain  is  intense,  often  leading  to  unconsciousness. 

The  diagnosis  rests  upon  the  absence  of  every  organic  disease 
characterized  by  pain  in  the  intestinal  region,  and  the  presence  of 
the  nervous  disease  or  the  neurotic  state.  The  treatment  is  that 
of  neuralgia,  (q.  v.)  Careful  inhibitory  treatment  over  the  sacral 
foramina  will  frequently  g^iive  relief. 

Intestinal  Anestl^sia  involves  the  sensory  nerves  of  the  anal 
region,  chiefly.  This  leads  to  neglect  of  defecation,  and  ultimately 
to  constipation.  In  organic  nervous  disease,  retained  motor  'power 
of  the  membranes  with  lost  sensitiveness  leads  to  involuntary  and 
often  spasmodic  defecation. 

Nervous  Diarrhea  is  characterized  by  frequent  stools  which 
show  no  abnormal  characteristics  other  than  that  they  may  be 
rather  softer  than  usual.  Occasionally  there  may  be  diarrhea  in  the 
morning,  with  no  trouble  during  the  rest  of  the  day  or  the  night. 
No  great  pain,  tenesmus  or  griping  is  present,  and  the  nutrition  is 
not  noticeably  impaired.  Such  attacks  are  frequent  in  neurotic 
individuals  after  excitements,  shock,  fatigue,  etc.  Any  calamity — 
an  earthquake,  for  example — is  apt  to  be  followed  by  many  such 
cases.  Care  should  be  taken  to  differentiate  possible  achylia. 
Grave's  disease  and  tabes  dorsalis.         ^ 

Enterospasm  is  a  spasm  of  the  circular  muscles  of  the  intestines ; 
it  may  be  so  great  as  to  cause  occlusion,  or  only  enough  to  diminish 
the  size  of  the  canal.  The  diagnosis  is  sometimes  difficult  and  cases 
in  which  total  occlusion  has  been  produced  in  this  manner  have 


56  THB  INTESTINES 

been  subjected  to  laparotomy.  The  tension  usually  subsides  under 
anesthesia,  returning  with  consciousness. 

Experimentally,  such  spasms  become  more  severe  with  ordinary 
stimulation,  such  as  manipulation,  salt  crystals,  heat  or  cold. 

When  the  diagnosis  has  been  made,  the  correct  treatment  is 
simply  the  correction  of  the  bony  lesions,  followed  by  complete 
rest  of  the  digestive  tract  as  well  as  of  the  entire  body.  Relaxation 
should  take  place  within  a  day,  or  two  days  at  most.  In  some 
cases  careful  inhibitory  work  over  the  spastic  area  will  give  relief. 

Nervous  Constipation.  In  hysterical  subjects,  especially,  con- 
stipation may  be  purely  a  neurosis.  Involuntary  or  reflex  move- 
ments, such  as  sneezing,  etc.,  may  then  precipitate  involuntary 
defecation.  Probably  most  of  these  hysterical  patients  suffer  from 
repressed  emotions  of  disgust,  and  are  best  treated  either  by 
psycho-analytic  methods,  or  by  a  frank  discussion  of  the  physio- 
logical needs  of  the  body,  with  such  methods  of  reeducation  as  seem 
best  adapted  to  the  mental  needs  of  the  patient. 

The  secretory  neuroses  include  deficient  secretion,  one  of  the 
causative  factors  in  constipation,  or  excessive  secretion,  which  is 
associated  with  mucous  colic. 

Mucous  Colic  (Colitis  colica;  enteritis  membranacea;  tubular 
diarrhea;  myxoneurosis  intestinalis;  sometimes  called  also  mucous 
colitis).  This  is  a  neurosis  affecting  the  large  intestine,  and  char- 
acterized by  the  secretion  of  large  quantities  of  mucus,  and  its 
passage  with  tenesmus,  and  colicky  pains.  Nervous  depression 
during  an  attack  is  common. 

Etiology.  It  is  chiefly  found  in  neurotic  women  and  girls. 
Direct  irritation  of  the  rectum  is  responsible  in  some  cases.  It  is 
found  in  men  who  ride  much  on  horseback  or  on  the  bicycle  or 
motorcycle.  Hardened  scybala  may  cause  attacks.  Attacks  are 
usually  precipitated  by  emotional  shocks,  fright,  etc.,  in  typical 
neurotic  patients.  Bony  lesions  include  chiefly  the  lumbo-sacral 
regions ;  less  commonly  the  innominates  and  the  mid-lumbar  spinal 
column.    Visceroptosis  is  frequent. 

Diagnosis.  The  diagnosis  rests  upon  the  symptoms  as  given, 
and  the  passage  of  long  ribbons  or  threads  of  mucus,  sometimes 
resembling  a  cast;  this  is  found  to  be  mucus  and  not  a  true  mem- 
brane by  microscopical  and  chemical  examination.  In  the  intervals 
between  the  attacks  no  symptoms  are  present ;  rectal  examination, 
X-ray,  etc.,  give  no  evidence  of  organic  disease,  although  care  should 
be  taken  that  the  colitis  is  not  secondary  or  symptomatic  of  chronic 
appendicitis,  cholecystitis  or  chronic  intestinal  obstruction. 

Treatment.  The  treatment  is  that  of  the  underlying  neurosis. 
Correction  of  the  bony  lesions  is  most  important.  Irrigation  of 
the  colon  gives  relief.    Rest,  good  hygiene,  sometimes  change  of  cli- 


COLIC  S7 

mate,  are  all  very  useful.  Place  patient  in  the  knee-chest  position 
and  carefully  elevate  sigmoid.  Direct  treatment  over  the  bowel, 
especially  the  lower  colon,  is  effective.  Do  not  treat  directly  if 
there  is  ulceration.  If  spastic  condition  is  marked  the  constipation 
will  be  increased. 

'  The  diet  is  important.  As  a  rule  do  not  prescribe  a  bland  one. 
Give  plenty  of  milk  and  cream,  butter  and  bacon,  coarse  vegetables 
and  fruits.  Thoroughly  masticated  skins  and  seeds  materially  help 
in  removing  the  mucus. 

Prognosis  is  good,  though  recovery  may  be  slow.  Patients  with 
local  rectal  irritations  recover  at  once,  on  the  removal  of  the  irri- 
tating agents.  Recurrences  are  to  be  expected,  if  the  original  cause 
is  allowed  to  persist. 

COLIC       ^ 

This  term  is  rather  loosely  employed  with  reference  to  abdom- 
inal pain  which  is  remittent  or  intermittent,  and  is  associated  with 
muscular  tension.  The  pain  is  very  often  extremely  severe,  and 
this,  with  the  apparent  collapse,  often  renders  an  immediate  diag- 
nosis impossible. 

The  first  necessity  is  relief  of  pain,  after  which  a  more  exact 
diagnosis  can  be  made.  This  relief  may  be  secured  by  the  appli- 
cation of  heat ;  by  pressure  upon  the  pit  of  the  stomach  or  around 
the  spinal  regions  of  most  contracted  muscles;  by  drinking  warm 
liquids ;  by  warm  enemas ;  by  compelled  long,  slow  respirations,' 
etc.  With  even  partial  relief  of  the  pain,  diagnosis  may  become 
evident. 

Intestinal  colic,  uncomplicated,  is  Indicated  by  little  or  no  vom- 
iting ;  some  sweating,  mild  degree  of  collapse  or  none ;  no  pyrexia ; 
pain  is  diminished  on  pressure,  or  application  of  heat ;  free  abdom- 
inal movements  with  respiration ;  slow  pulse  or  only  slight  increase 
in  rate ;  patient  not  rigid  in  position ;  history  of  constipation  or  of 
improper  food  or  of  emotional  storm  or  of  some  other  efficient 
cause,  or  of  previous  attacks. 

Inflammatory  diseases  of  the  intestines  may  give  rise  to  this 
symptom.  This  is  indicated  by  rise  of  temperature  (above  1CX)°  F.), 
rapid  pulse,  diarrhea,  pain  increased  on  pressure  or  application  of 
heat;  abdominal  muscles  rigid  during  respiratory  movements;  posi- 
tion of  patient  rigid,  varying  according  to  location  of  inflammatory 
piocess ;  local  symptoms,  etc.  In  peritonitis  and  adhesions  localized 
in  movable  parts  the  pain  is  usually  in  the  region  of  the  umbilicus; 
if  localized  in  fixed  parts,  the  pain  is  usually  in  the  region  affected. 

Perforation  Is  Indicated  by  severe  collapse,  history  of  possible 
causes  of  perforation,  etc.     Intestinal  obstruction  gives  repeated 


58  THE  INTBSTINBS 

vomiting  which  becomes  fecal ;  gastric  crises  in  locomotor  ataxia 
and  other  nervous  diseases  give  pupillary  and  other  symptoms. 

In  children  the  referred  pain  in  Pott's  disease  and  appendicitis 
may  simulate  colic. 

Colic  of  the  ileo-cecal  region  has  been  described  in  connection 
with  the  passage  of  large,  hard  material  through  that  valve,  or  its 
retention  in  that  region.  Adhesions  may  be  a  causative  factor.  The 
diagnosis  is  suspected  upon  the  occurrence  of  colicky  pain  in  the 
right  iliac  fossa,  without  fever,  with  sudden  termination  and  no 
recurrence.  The  diagnosis  is  verified  upon  the  appearance,  a  few 
hours  later,  of  the  hard  material  in  the  feces.  (The  delay  in  the 
colon  may  be  several  days  or  more  than  a  week.) 

Renal  colic.  The  passage  of  renal  calculi  may  simulate  colic. 
The  pain  radiates  downward,  to  the  labia  in  the  female  or  the 
testicle  and  penis  in  the  male,  to  the  thigh  in  either;  frequent  void- 
ing of  small  amounts  of  urine,  which  contains  blood  and  kidney 
epithelium  make  the  diagnosis  certain ;  the  X-ray  may  give  the 
exact  diagnosis.  In  tubercular  kidney  the  passage  of  masses  of  pus 
and  coagulated  blood  may  cause  renal  colic. 

Pancreatic  colic  is  very  rare  and  probably  impossible  of  definite 
ante  mortem  diagnosis  without  exploratory  incision.  Intense  jaun- 
dice and  large  gall  bladder  due  to  the  occlusion  of  the  ductus  chole- 
dochus  by  the  pancreatic  stone,  or  to  the  swollen  and  inflamed  duct 
in  pancreatitis,  confuse  the  diagnosis  with  biliary  colic.  Pigmenta- 
tion of  the  skin  with  wasting  may  lead  to  a  suspicion  of  the  disease, 
which  is  further  justified  by  the  finding  of  undigested  fat  and  starch 
particles  in  the  feces;  a  large  and  very  pale,  oflfensive  stool  is 
characteristic. 

Biliary  colic,  due  to  the  passage  of  gall  stones  through  the 
duct,  is  usually  easily  recognized.  Vomiting,  sweating,  shivering 
and  signs  of  collapse,  the  expression  of  terrible  anxiety  and  pain, 
with  the  location  of  the  pain  over  the  gall  bladder,  and  darting  into 
the  right  shoulder,  render  the  diagnosis  easy,  as  a  rule.  Deep  ten- 
derness over  the  gall-bladder  is  very  suggestive.  When  the  stone 
occludes  the  duct  the  jaundice  may  be  very  severe.  After  an 
attack  the  feces  should  be  strained  and  washed.  Until  the  stone  is 
found  and  examined.  X-ray  plates,  especially  stereoscopic,  are 
helpful. 

Lead  colic.  This  form  of  colic  may  be  recognized  by  the  pres- 
ence of  the  blue  line  around  the  gums ;  the  history  of  working  in 
paint,  in  lead  mines,  etc.,  or  of  drinking  water  or  beer  which  has 
stood  in  lead  pipes;  by  the  associated  nervous  symptoms,  such  as 
wrist-drop,  and  by  the  lack  of  fever,  the  rapid  anemia  and  the 
mucous   hemorrhages;   urinalysis   shows  mild   nephritis   findings. 


COUC  59 

The  blood  shows  secondary  anemia  plus  basophilic  granules  in  the 
erythrocytes.    Pressure  relieves  the  pain. 

INTESTINAL  COLIC 

(Enteralgia;  tormina;  gripes) 

Intestinal  colic  is  a  spasmodic  contraction  of  the  muscular  layer 
of  the  intestines  occurring  as  a  symptom  of  several  intestinal  dis- 
eases and  also  alone.  It  is  characterized  by  acute  paroxysmal  pain 
near  the  umbilicus  which  is  relieved  by  pressure  and  is  associated 
with  feeble  heart  action. 

Etiology.  Constipation,  the  presence  of  undigested  food,  abnor- 
mal amounts  of  bile  in  the  intestinal  tract,  structural  lesions  of  the 
intestinal  wall,  lead  poisoning,  various  diseases,  and  reflex  impulses 
are  all  causative.  Lesions  of  the  splanchnic  area,  interfering  with 
the  normal  control  of  the  muscular  activity  of  the  intestines  and 
secretions  of  the  mucous  membranes  are  also  of  utmost  impor- 
tance in  the  etiology. 

Diagnosis.  Paroxysmal  pain  of  a  tearing,  cutting,  pressing, 
twisting,  pinching,  or  bearing  down  character,  centering  around 
the  umbilicus,  is  the  main  symptom.  The  abdomen  is  tense  and 
pressure  relieves  the  pain.  In  severe  attacks  the  surface  is  cold, 
the  features  pinched,  the  pulse  small  and  hard,  and  there  may  be 
nausea,  vomiting  and  tenesmus.  Constipation  is  usual.  The  dura- 
tion is  from  a  few  minutes  to  several  hours,  often  with  intermis- 
sions and  usually  terminating  by  the  discharge  of  flatus. 

Muscular  contractions  may  be  found  along  the  spine  corre- 
sponding to  the  area  involved.  There  may  be  a.  definite  subluxa- 
tion either  of  the  vertebrae  or  ribs  which  may  bear  a  causative 
relation.    The  abdomen  is  tense  but  not  painful  on  palpation. 

Treatment.  As  soon  as  the  attack  appears,  hot  moist  com- 
presses or  a  hot  water  bottle  may  give  relief — this  may  precede 
the  arrival  of  the  physician.  Relief  of  the  acute  pain  is  the  first 
essential.  Muscular  contractions  will  be  found  in  the  spinal  areas 
corresponding  to  the  intestinal  area  affected ;  commonly  the  eighth 
to  the  eleventh  thoracic  for  the  small  intestine  and  the  second  to 
the  fourth  lumbar  for  the  large  intestine.  Deep,  steady  pressure, 
gradually  increasing,  over  these  muscles  and  near  the  spinal  proc- 
esses of  the  corresponding  vertebrae  will  give  relief;  a  hot  pad  over 
the  same  area  may  prevent  sul)sequent  contraction.  In  any  case, 
the  treatment  is  best  applied  to  the  areas  of  reflex  muscular  contrac-^ 
tion.  (The  higher  the  area  affected,  the  longer  time  is  usually 
required  for  relief,  under  ordinary  medical  treatment.  Little  dif- 
ference is  noted  under  osteopathic  care.)  When  the  muscular  con- 
tractions have  disappeared,  bony  lesions  in  the  same  area  are  fre- 


60  THB  INTESTINES 

quently  found.    Correction  of  these  facilitates  more  rapid  recovery 
and  helps  to  prevent  recurrence  of  the  attack. 

If  the  abdominal  muscles  are  contracted  or  if  the  intestinal 
contractions  are  palpable  a  gentle  manipulation  of  these  contracted 
areas  is  indicated.  If  possible  utilize  the  knee-chest  position  and 
carefully  locate  and  release  the  tissues  about  the  tender  area. 
Deep,  steady  pressure  over  the  solar  plexus  may  relieve  the  pain, 
promote  normal  peristalsis,  and  thus  the  elimination  of  gas  and 
feces.  Raising  the  ribs  increases  the  rapidity  of  the  circulation, 
raises  the  blood  pressure  and  thus  helps  in  carrying  away  carbon 
dioxide  from  the  intestines  to  the  lungs  and  thus  from  the  body. 
If  conditions  permit,  abstinence  from  all  food  for  two  or  three  days, 
with  plenty  of  hot  water  to  drink,  will  release  the  spinal  rigidness 
so  that  adjustment  is  comparatively  easy.  Regulation  of  the  diet 
and  correction  of  bad  habits  is  essential  to  permanent  recovery. 

Prognosis.  Recovery  is  to  be  expected,  with  proper  treatment, 
in  a  few  minutes  to  a  fe\v  hours.  Recurrence  is  to  be  expected  if 
the  original  causes  persist  or  recur.  Important  in  prophylaxis  are 
the  correction  of  bony  lesions ;  the  removal  of  low  iDlood  pressure ; 
the  modification  of  diet;  and  the  establishment  of  normal  bowel 
habits. 

CONSTIPATION 

(Costiveness;  intestinal  torpor) 

Constipation  is  the  retention  of  feces  in  the  colon  for  a  longer 
time  than  is  normal  to  the  individual,  resulting  in  abnormally  dry, 
hard  feces,  usually  voided  at  irregular  and  considerable  intervals. 

Etiology.  The  causes  are  dietetic,  habitual  and  nervous,  local, 
and  constitutional. 

The  dietetic  errors  include :  Diets  of  too  concentrated  foods,  or 
of  too  little  quantities,  which  fail  to  give  normal  mechanical  stim- 
ulus ;  diets  of  too  great  preponderance  of  waste  material  and  of 
too  great  abundance,  thus  dilating  the  colon ;  and  those  containing 
too  little  water. 

Habitual  and  nervous  errors  include:  Failure  to  defecate  at 
proper  intervals,  especially  at  the  natural  stimulus ;  use  of  drugs ; 
abnormal  control  of  the  nerve  centers,  due  especially  to  bony 
lesions  of  the  innominates,  sacrum,  coccyx,  and  the  lumbar  ver- 
tebrae; to  frequent  jarring,  as  of  cars,  etc.,  and  to  hysteria  and  the 
neurasthenic  states. 

Local  disturbances  of  the  muscles  of  the  cecum,  colon,  sigmoid 
and  rectum  and  of  those  of  defecation,  and  local  disturbances  of 
sensation  of  the  rectal  and  anal  region  may  be  due  to  wrong 
position  at  stool  (the  modern  toilet  seat  is  abomiwable)  ;  the  pres- 
sure of  clothing;  atony  with  or  without  visceroptosis;  deficiency 


CONSTIPATION  61 

of  the  digestive  secretions  and  of  mucus ;  stenosis,  due  to  cicatrices 
or  to  contractions  of  the  sphincters;  hemorrhoids,  fissures,  ulcera- 
tions or  coccygodynia.  Local  obstructions  may  be  due  to  tumors, 
uterine  malposition,  pregnancy,  enlarged  prostrate  or  others. 

Constitutional  causes  include  certain  anemias,  acute  fevers,  and 
cerebral  affections. 

There  may  be  hypertrophy  of  the  muscular  coat  of  the  descend- 
ing colon  or  there  may  be  small  ulcers  in  the  cecum ;  there  may  be 
thinning  of  the  walls  and  dilatation  of  the  whole  colon.  Enterop- 
tosis  is  frequent.  The  sigmoid  may  be  congenitally  longer  and 
more  tortuous  than  normal.  Intestinal  atony  and  intestinal  spasm 
are  frequent.  Spasticity,  inflammation  and  adhesions  of  the  sig- 
moid area  are  common  causes. 

Diagnosis.  The  main  symptoms  are  diminution  in  the  fre- 
quency of  the  bowel  movements;  the  feces  are  of  undue  hardness; 
there  is  need  for  great  straining  at  stool ;  defecation  may  be  painful. 
The  local  symptoms  are :  Sensation  of  fullness  and  weight  in  the 
rectum  or  in  the  abdomen;  spurious  diarrhea  or  diarrhea  of  con- 
stipation with  some  pain,  tormina,  or  tenesmus  but  not  giving 
relief  to  the  fullness;  pain  in  the  left  groin  and  down  the  left 
thigh  and  in  the  back. 

The  general  symptoms  are  many  times  lacking.  Debility,  lassi- 
tude, fetid  breath,  impaired  digestion,  vertigo, .  variable  appetite, 
furred  tongue,  flatulence,  depression  and  mental  torpor  may  occur. 
Dilatation  and  ulceration  of  the  colon,  piles  and  hemorrhoids  may 
ensue.  The  colon  may  be  outlined  by  palpation,  being  filled  with 
a  "doughy-feeling"  mass.  The  abdomen  is  distended.  The  diag- 
nosis is  to  be  made  carefully ;  sometimes  only  a  purgative-habit  is 
present;  occasionally  "the  patient  only  supposes  himself  constipated 
on  account  of  some  personal  idiosyncrasy.  Careful  examination 
is  necessary  to  determine  the  actual  condition  present  and  to  elicit 
as  much  information  concerning  the  habits  as  possible.  Constipa- 
tion is  more  often  a  symptom  than  an  actual  disease. 

The  X-ray  is  invaluable.  Barium  or  bismuth  enemas  show  the 
size,  position  and  activity  of  the  colon,  sigmoid,  and  rectum. 

Treatment.     Purgative  medicines  must  be  stopped  absolutely. 

The  correction  of  structural  mal-adjustments  is  of  prime  impor- 
tance. Dorso-lumbar  rigidity  must  be  relieved.  Corrective  treat- 
ments should  be  given  briskly,  thus  restoring  something  of  normal 
stimulation  to  the  inactive  nerve  centers  of  the  dorso-lumbar  spinal 
segments.  However,  if  spinal  adjustment  is  specific  and  immediate 
normalization  of  nerve  impulses  will  shortly  be  forthcoming. 
Treatment  of  the  ileo-cecal  and  sigmoid  areas  while  the  patient 
is  in  the  knee-chest  position  is  effective.  The  lower  ribs  should  be 
raised ;  this  may  be  associated  with  forced  respiratory  movements, 
to    advantage.      Lesions    should    be    corrected,    wherever    they 


62  THE  INTESTINES 

occur;  indirectly,  distant  lesions  may  be  efficient  etiological  factors 
in  constipation  or  diarrhea. 

A  regular  habit  of  going  to  stool  must  be  taught.  Beside  going 
at  a  certain  fixed  hour  each  day,  the  patient  niust  remain  a 
sufficiently  long  time  to  allow  a  thorough  evacuation.  A  small 
warm  water  enema  may  be  used  to  start  the  fecal  column  when 
necessary.  Using  a  stool  under  the  feet  of  a  sufficient  height  to 
bring  the  knees  well  up  above  the  plane  of  the  iliac  crests,  helps 
make  the  lines  of  pressure  exerted  by  the  accessory  respiratory 
muscles  in  the  expulsion  more  nearly  normal.  The  pressure  is 
thrown  upon  the  descending  fecal  column  rather  than  upon  the 
fundus  of  the  uterus  or  upon  the  prostatic  region. 

"The  intelligent  treatment  of  constipation  is  no  exception  to  the  rule  and 
depends  upon  diagnosis,  and,  of  course,  will  vary  somewhat  according  to  the 
case.  I  very  seldom  see  a  case  oftener  than  twice  a  week,  many  cases  only  once  a 
week.  All  osteopathic  lesions  that  could  in  any  way  be  contributing  factors 
are  given  appropriate  treatment.  If  faulty  posture  has  contributed  to  these 
conditions,  the  patient's  attention  is  called  to  the  fact,  and  his  or  her  coopera- 
tion requested.  I  assure  myself  that  my  women  patients  are  wearing  properly 
fitted  corsets  arid  that  they  know  how  to  put  them  on." — E.  C.  Bond. 

Dietetic  errors  as  found  must  be  corrected.  In  some  cases,  a 
bulky  diet  is  advisable  with  many  vegetables  and  fruits.  In  these 
cases  exclude  all  meats;  this  will  change  the  intestinal  flora.  Two 
to  four  tablespoonfuls  of  flax  seeds  per  day,  swallowed  without 
mastication,  will  carry  considerable  moisture  to  lower  bowel. 
Paraffin  oil  by  mouth  softens  the  fecal  mass.  Water  must  be  used 
sufficiently  to  produce  a  normal  quantity  of  the  digestive  juices,  at 
least  two  quarts  each  day.  Systematic  exercises  are  necessary  to 
a  recovery.  Walking  is  the  best  as  it  brings  all  muscles  into  play. 
Various  games  and  gymnasium  exercises  are  good.  Special  exer- 
cises should  be  planned  for  each  patient. 

The  immediate  evacuation  of  large  masses  of  fecal  material, 
long  retained,  and  dry  in  the  colon,  is  not  usually  wisely  attempted. 
Cleansing  the  lower  bowel  by  warm  normal  saline  enemas  is 
indicated.  The  container  should  not  be  more  than  two  feet  above 
the  body,  so  the  water  can  flow  without  great  pressure.  Only 
small  amounts  should  be  used  at  any  one  time,  to  prevent  dis- 
tention. When  the  first  water  has  been  ejected,  another  small 
quantity  may  be  used,  and  so  on  until  the  rectum  is  fairly  well 
cleansed.  The  next  day  the  performance  is  repeated,  and  so  on 
until  the  colon  appears  empty  of  the  offending  material.  When 
the  water  is  irritating,  or  when  it  fails  to  properly  soften  the 
fecal  masses,  warm  oil  or  bland  solutions  of  soap,  glycerine  or 
molasses  may  be  used.  The  oil  may  be  permitted  to  remain  over 
night  or  for  several  hours  in  the  sigmoid.  Care  should  be  taken 
to  avoid  fatigue. 

Uterine  mal-positions  should  be  corrected.  Tumors,  enlarged 
prostate,  and  other  local  obstructions  must  receive  such  treatment 


CONSTIPATION  63 

as  is  indicated  on  examination.    Piles  and  hemorrhoids  may  require 
surgical  care.    Sometimes  palliative  treatment  is  useful. 

The  following  treatment  for  hemorrhoids  is  given  by  Dr.  Ella  D.  Still : 
"Find  and  treat  cause  for  constipation ;  next,  replace  coccyx ;  last,  straighten 
up  rectal  tissues.  Put  patient  in  genu-pectoral  position,  introduce  finger  and 
gently  push  the  tissue  up,  having  the  patient  inhale  deeply  during  the  time.  I 
carefully  dilate  sphincters,  first  introducing  one  and  then  later  two  fingers.  All 
this  should  be  gently  done,  otherwise  the  parts  are  irritated.  Particularly  in 
bleeding  hemorrhoids,  have  the  patient  wash  out  the  lower  bowel  each  time 
after  defecation,  for  the  parts  must  be  kept  clean.  Use  only  a  small  amount  of 
water,  never  more  than  a  pint." 

"In  considering  hemorrhoids  one  must  recognize  that  there  are  those  that 
may  be  successfully  treated  by  non-surgical  methods.  Those  responding  to  such 
treatment  are  what  are  termed  simple  hemorrhoids  where  vessels  are  dilated 
but  no  great  tissue  change  has  taken  place,  the  causes  for  which  may  be  located 
anywhere  from  liver  to  rectal  sphincters.  These  cases  demand  thorough  exam- 
ination as  cures  cannot  be  expected  unless  cause  is  removed. 

"When  there  are  bony  lesions  I  find  the  innominate  and  sacro-coccygeal 
most  common.  In  women,  where  displaced  pelvic  organs  are  the  cause  of 
trouble,  treatment  must  be  directed  to  that  area.  Constipation  must  be  relieved 
and  rectal  sphincters  dilated.  In  nearly  every  case  there  is  more  or  less  pro- 
lapsing of  rectal  tissues  which  I  straighten  out  by  first  placing  patient  in  Sims 
position  while  I  carefully  dilate  rectal  sphincters.  Then  have  patient  assume 
genu-pectoral  position  while  I  gently  push  up  on  rectal  walls,  thereby  lifting 
the  hemorrhoidal  veins. 

"The  postural  treatment  may  be  used  by  patients   daily  to  good  eflfect." — 
Ella  D.  Still. 

In  order  to  prevent  hemorrhoids  and  piles,  and  to  delay  the 
progress  of  these  conditions  after  they  have  been  initiated,  the 
use  of  warm'  water  or  oil  to  soften  the  fecal  mass  should  be 
employed  daily,  until  no  longer  necessary.  The  use  of  small 
quantities  of  water  for  this  purpose  is  no  more  abnormal  than 
is  the  use  of  soap  and  water  for  cleaning  the  skin  of  the  surface 
of  the  body,  or  the  use  of  oils  for  softening  any  kind  of  dirt  which 
might  have  dried  upon  the  skin.  The  need  for  this  procedure 
should  be  temporary,  as  the  correct  treatment  should  bring  nor- 
mally soft  fecal  masses  to  the  rectum.  Remember  that  in  ulcera- 
tion and  marked  spastic  states  manipulation  of  the  bowels  is  con- 
traindicated. 

It  is  important  to  know  when  to  advise  surgery  in  these  cases, 
and  when  to  endeavor  to  relieve  conditions  by  palliative  measures. 

"So  long  as  the  veins  retain  their  tonicity  and  there  are  no  thrombosed  areas 
or  the  vein  walls  have  not  thickened  to  any  great  degree  or  the  hemorrhage  is 
not  too  profuse,  osteopathy  will  cure  almost  every  case  if  the  doctor  who  has 
the  patient  in  charge  will  insist  upon  a  thorough  course  of  treatment.  As  a 
rule,  when  the  hemorrhage  is  profuse  and  frequent,  when  the  vein  walls  are 
thickened  with  or  without  much  prolapse  or  when  the  piles  are  very  painful, 
surgery  has  its  place  and  can  cure  most  of  these  cases.  Many  of  them  require, 
however,  a  combination  of  surgery  and  osteopathy  to  effect  a  cure,  for  constipa- 
tion and  portal  circulatory  disturbances  must  be  cleared  up  before  one  can  be 
positive  that  the  condition  will  not  recur." — S.  L,.  Taylor. 

Prognosis.  The  outlook  is  favorable  for  recovery  but  the  course 
is  likely  to  be  prolonged.    As  complications  and  sequelae,  are  to  be 


64  THE  INTESTINES 

mentioned  hemorrhoids,  impaction,  anal  fissures,  and  ulceration  of 
the  colon  or  rectum. 


INTESTINAL  AUTOINTOXICATION 

(Chronic  intestinal  stasis;  Rigg's  disease) 
Intestinal  autointoxication  is  a  condition  due  to  the  retention 
and  absorption  of  toxins  produced  in  the  intestinal  tract,  and  char- 
acterized by  vertigo  and  headache,  furred  tongue,  foul  breath, 
anorexia,  stomatitis,  and  symptoms  of  kidney,  liver  and  bowel 
inactivity  without  organic  disease  of  these  organs. 

Etiology.  The  causes  of  the  condition  are  not  well  understood. 
The  formation  of  toxic  substances  by  the  membrane  of  the  upper 
intestinal  tract  has  been  experimentally  demonstrated.  Ileal  stasis, 
enteroptosis  and  adhesions  are  other  causes;  these  conditions  can 
best  be  recognized  by  a  study  of  X-ray  plates,  usually  with  barium 
or  bismuth  meals.  Dietetic  errors,  constipation,  lesions  involving 
the  lower  thoracic  and  upper  lumbar  spinal  column  and  the  lower 
ribs,  and  a  generally  depressed  state  of  the  nervous  system  are 
considered  causative  factors.  Deficient  water  intake,  and  deficient 
oxygen  supply  are  certainly  often  important  in  etiology. 

"The  dietetic  errors  frequently  include  too  high  proteid  intake.  Any  diet 
which  is  unbalanced  may  cause  the  condition ;  food-faddists  of  any  type  are  very 
subject  to  the  trouble.  Disturbed  relations  of  the  various  groups  of  intestinal 
flora,  and  of  these  with  the  digestive  secretions,  have  been  considered  causative. 
A  lack  of  the  bacilli  coli  communis  has  been  considered  responsible,  and  attempts 
made  to  treat  the  disease  by  giving  cultures  of  this  organism  in  alkali-soluble 
capsules.  Sour  milk  and  cultures  of  lactic  acid  bacilli  have  also  been  used, 
according  to  the  Metchnikoff  theories.  Recent  investigations  show  a  toxic  ele- 
ment in  the  succus  entericus,  which,  injected  into  the  bodies  of  animals,  cause 
the  symptoms  of  autointoxication  of  the  intestinal  type.  The  absorption  of  the 
albumoses  and  the  leucomaines  give  at  least  a  part  of  the  symptoms  observed ; 
these  are  products  of  proteid  digestion  which  are  not  normally  absorbed  as  such." 

"In  sixteen  years'  experience  the  writer  has  yet  to  find  a  case  of  chronic 
intestinal  stasis  without  a  related  spinal  lesion,  demonstrated  either  as  flaccid 
or  tensed  muscles  and  ligaments  or  bony  maladjustments.  And  they  always 
related  to  that  area  of  the  spine  between  the  sixth  dorsal  and  second  lumbar. 
We  have  considerable  laboratory  proof  that  such  spinal  lesions  have  a  detri- 
mental effect  upon  intestinal  function,  and  an  abundance  of  clinical  proof  that 
the  removal  of  such  lesion  almost  invariably  results  in  partial  or  complete  cure." 
— J.  J.  Pearce. 

The  mental  depression  is  associated  with  flabby  muscles,  much  after  the 
fashion  of  the  melancholia  patient.  The  effect  of  the  toxin  upon  the  cerebral 
centers  is  not  to  be  denied,  yet  there  seems  much  evidence  in  favor  of  the 
view  that  the  deficient  nervou§  activity  is  also  a  cause  of  the  intestinal  state. 
The  undoubted  value  of  psycho-analysis  in  some  of  these  cases  is  also  indica- 
tive of  the  place  of  cerebral  activity  in  the  control  of  intestinal  functions.  The 
symptoms  of  autointoxication  which  so  often  follow  depressing  emotional  states 
is  well  known.  All  of  these  variable  etiological  factors  show  that  the  control 
of  intestinal  activity  is  either  a  much  more  complicated  affair  than  has  been 
supposed,  or  that  the  true  cause  of  intestinal  autointoxication  has  not  yet  been 
discovered. 


AUTOINTOXICATION  65 

The  autopsy  findings  include  evidences  of  toxemia,  affecting  many  organs. 
The  intestines  may  be  overfilled,  in  segments  or  generally;  ulcers  may  some- 
times be  found  in  the  small  intestine. 

Diagnosis.  Only  after  every  organic  disease,  anaphylaxis,  intes- 
tinal infection  and  food  poisoning  with  similar  symptoms  have 
been  eliminated  is  a  diagnosis  of  intestinal  autointoxication  justifi- 
able. A  too  facile  and  faulty  diagnosis  of  this  condition  may  permit 
organic  disease  to  progress  to  an  incurable  stage. 

The  symptoms  are  widely  distributed.  Constipation  usually 
alternates  with  diarrhea,  while  the  anorexia,  nausea,  foul  breath, 
furred  tongue  persist  with  little  or  no  remission.  Flabby  muscles, 
sallow  skin,  and  emaciation  are  constant.  Vague  sensory  disturb- 
ances, such  as  fleeting  pains,  rheumatic-like  aching,  formication, 
alternations  of  heat,  cold,  and  prickly  sensations,  skin  lesions,  visual 
disturbances,  tinnitus,  and  disturbances  in  taste  and  smell,  are 
variably  found.  Vertigo  and  headache,  sometimes  resembling  mi- 
graine, palpitation,  cold  hands  and  feet  and  varying  blood  pressure 
are  characteristic.  Insomnia  alternates  with  bad  dreams  in  some 
cases,  while  in  others  sleep  is  abnormally  profound  and  of  many 
hours'  duration.  Apathy  and  despondency  may  approach  melan- 
cholia. Disturbed  function  of  many  organs  of  the  body  may  be 
caused  by  the  toxemia  and  the  nervous  reflexes,  and  organic  dis- 
ease may  supervene. 

The  physical  examination  must  be  thorough,  in  order  to  elim- 
inate organic  disease.  The  thyroid  gland  is  often  slightly  enlarged. 
The  tongue  is  furred,  the  breath  foul  and  often  sweetish.  There 
may  be  a  hemic  murmur,  and  the  cardiac  sounds  are  weak.  Slight 
rales  may  be  heard  on  taking  unusually  long  breath.  Slight  or  no 
gastric  dilatation  is  to  be  found.  The  liver  is  slightly  enlarged, 
and  is  found  slightly  lower  than  usual,  under  the  depressed  ribs. 
The  spleen  is  sometimes  enlarged.  (Both  liver  and  spleen  may  be 
tender  and  may  ache  like  "ague  cake,"  which  has  often  led  to 
faulty  diagnosis  of  malaria.)  Abdominal  tenderness  is  usually 
present,  not  well  localized,  and  varjnng  daily. 

The  skin  and  underlying  tissues  are  tender  on  palpation  around 
the  neck  and  shoulders,  especially  near  the  suboccipital  regions,  the 
tips  of  the  shoulders,  and  the  neighborhood  of  the  transverse  proc- 
esses of  the  cervical  vertebrae.  The  cervical  muscles  are  hypersen- 
sitive, a  condition  much  resembling  torticollis  may  be  present.  An 
area  of  tension  with  tenderness  is  found  in  the  neighborhood  of  the 
fifth  to  the  eighth  thoracic  spines,  extending  outward  over  the 
heads  of  the  ribs.  This  is  usually  the  upper  limit  of  a  spinal  mal- 
adjustment extending  to  the  second  lumbar  vertebra  or  lower. 
Through  this  area  the  spinal  column  is  unduly  rigid,  and  the  tissues 
are  apt  to  be  more  or  less  analgesic  and  sometimes  anesthetic. 
Rarely   hyperalgesia   is   present   through    this   area.     Innominate 


66  THE  INTESTINES 

lesions  and  lumbo-sacral  lesions  may  be  present,  and  may  be  the 
primary  cause  of  the  dorso-lumbar  lesions. 

The  urine  shows  excess  of  indican,  the  conjugated  sulphates, 
and  sometimes  acetone.  Albumin  and  casts  and  renal  epithelium 
may  suggest  nephritis ;  the  celerity  with  which  the  condition  clears 
up  proves  the  disturbance  functional.  There  may  be  lessened 
sugar  tolerance;  small  amount  of  sweets  being  followed  by  glyco- 
suria; this,  with  the  acetone  and  aromatic  urinary  content  may 
suggest  diabetes;  here,  also,  the  transient  nature  of  the  findings 
gives  the  diagnosis. 

The  blood  shows  the  efifect  of  the  toxins.  Atypical  forms  are 
found  in  each  class  of  blood  cells.  Both  red  and  white  cells  are 
often  fractured.  Eosinophilia  may  be  marked ;  amphophiles  and 
basophiles  are  occasionally  found.  Nuclei  may  be  extruded ; 
nuclear  masses  may  be  plentiful. 

A  teaspoonful  of  powdered  charcoal  should  be  given,  with  food, 
and  the  time  recorded.  The  first  appearance  of  a  black  color  in 
the  feces  should  be  recorded,  and  then  the  time  when  the  black 
color  disappears  from  the  feces  be  recorded.  This  gives  the  time 
relations  of  the  intestinal  passage.    The  X-ray  is  much  more  exact. 

Treatment.  This  must  be  based  upon  the  factors  found  impor- 
tant in  the  etiology  of  each  case.  Special  attention  should  always 
be  given  to  the  ascending  colon  and  the  sigmoid. 

Bony  lesions  must  be  corrected.  The  required  corrective  treat- 
ments should  be  given  briskly,  in  such  a  manner  as  to  stimulate  the 
sensory  nerve  endings  in  the  articular  tissues  and  the  deeper 
muscular  layers  along  the  spinal  column  and  around  the  heads  of 
the  ribs.  The  ribs  should  be  raised  and  held  for  the  space  of  one 
to  three  long,  slow  breaths.  Nearly  all  corrective  treatment 
usually  indicated  in  this  condition  may  be  given  in  such  a  way 
as  to  compel  forced  and  deep  respiratory  movements ;  these  are 
excellent. 

The  patient  should  be  taught  correct  posture,  such  exercises  as 
his  individual  peculiarities  demand,  and  correct  breathing  habits. 

When  investigation  indicates  repressed  emotional  states,  some 
of  the  methods  used  in  psycho-anal3^sis  are  indicated. 

Purgatives  must  be  absolutely  discontinued.    The  colon  should 

be  kept  clean  by  enemas;  this  constant  removal  of  passages  from 

'the  small  intestine,  with  very  much  increased  water  drinking,  are 

all  that  the  ileum  and  jejunum   require  in  the  way  of  laxative 

treatments,  provided  adhesions  are  not  present. 

"Latterly  I  have  been  using  bowel  irrigations  in  these  cases — with  or  with- 
out fasting — varying  in  frequency  from  once  in  two  days  to  three  times  each 
day.  Six  to  fourteen  quarts  of  water  are  used ;  if  there  is  colitis,  as  is  usual, 
the  water  is  slightly  Soapy.  In  all  these  cases  the  great  essential  is  the  adjust- 
ment work  in  the  dorsal  or  lumbar  areas.  Fasting  and  irrigation  are  necessary 
for  anything  like  rapid  recovery.     Results  are  very  gratifying." — G.  W.  Riley. 


AUTOINTOXICATION  67 

After  a  fast,  a  rigid  milk  diet,  or  rigid  fruit  diet,  or  some  other 
rigid  diet  chiefly  of  water  and  associated  with  rest  and  other  indi- 
cated treatment,  should  be  given  until  the  toxic  symptoms  abate. 
The  juice  of  lemons,  limes,  grape  fruit  and  pineapple  greatly 
diluted  are  excellent. 

After  the  body  seems  clean,  the  return  to  a  mixed  diet  must 
be  made  cautiously.  Whatever  class  of  food  has  been  taken  in 
excessive  amounts  before  and  during  the  onset  of  the  toxic  symp- 
toms, should  now  be  almost  or  quite  omitted  from  the  diet  for 
a  long  time.  The  patient  must  never  return  to  an  unbalanced  diet. 
Probably  he  will  need  more  cellulose  and  raw  foods,  and  more 
liquid,  than  do  normal  persons  for  months  or  years  after  the 
attack,  in  order  to  prevent  recurrence. 

With  return  to  mixed  diet,  an  attempt  must  be  made  to  increase 
the  fat  and  the  muscular  tone  of  the  body.  Systematic  exercises, 
both  mental  and  physical,  are  important.  Since  the  condition  is 
often  of  slow  development  and  itself  causes  mental  depression,  the 
reeducation  of  the  patient  is  a  necessary  element  in  promoting  the 
most  rapid  recovery. 

Prognosis  and  Sequelae.  The  toxemia  predisposes  to  certain 
functional  and  organic  diseases.  Hysteria  and  the  neurasthenic 
states,  anemia,  arterio-sclerosis,  interstitial  nephritis  and  cirrhosis 
of  the  liver,  may  be  mentioned,  to  say  nothing  of  the  effects  upon 
the  life  of  the  patient  of  the  mental  habit  of  apathy  and  torpor. 
With  suitable  treatment  and  reeducation,  many  of  these  after- 
effects can  be  avoided.  Recovery  is  to  be  expected  as  long  as  the 
intestinal  autointoxication  remains  uncomplicated  by  organic  dis- 
ease, provided  the  patient  is  obedient  to  the  instructions  and  is  will- 
ing to  receive  the  treatment  indicated  for  the  weeks  or  months  nec- 
essary to  complete  restoration  to  correct  bodily  structure  and 
cellular  metabolism. 


CHAPTER  VI 
DISEASES  OF  THE  INTESTINES— (Continued) 

GASTRO-ENTEROPTOSIS 

(Glenard's  disease;  asthenia  generalis;  splanchnoptosis;  visceroptosis;  visceral 

prolapse) 

This  is  unfortunately  a  rather  common  condition.  It  is  a 
downward  displacement  of  the  stomach  and  intestines,  usually 
including  the  stomach  and  the  colon,  often  the  small  intestines, 
the  right  kidney  and  the  spleen.  The  colon  frequently  hangs  into 
the  true  pelvis;  the  pyloric  end  of  the  stomach  may  also  be  found 
in  the  true  pelvis. 

Etiology.  The  causes  are  congenital  and  acquired.  Imperfect 
development  of  the  supporting  ligaments  and  of  the  muscular  walls 
of  the  viscera  and  of  the  abdomen,  with  or  without  a  general  bodily 
weakness  associated  with  a  tendency  to  kyphosis,  are  the  most 
common  congenital  causes.  Of  the  acquired  causes,  two  chief 
classes  may  be  recognized :  weakness  of  the  muscles  and  ligaments, 
and  increased  weight  of  the  viscera. 

Weakness  of  the  supporting  tissues  has  as  its  chief,  or  as  a 
contributing  cause,  some  abnormal  spinal  condition,  either  a  kypho- 
sis, which  may  act  mechanically  or  as  a  bony  lesion,  or  the  less 
conspicuous  subluxations.  Faulty  postures  act  in  the  same  way. 
These  practically  always  include  a  rigidity  of  the  lower  thoracic  or 
the  dorso-lumbar  spinal  column  and  a  dropping  of  the  lower  ribs, 
with  lessened  mobility  of  the  lower  chest  wall.  Congenital  absence 
of  the  tenth  costal  cartilages  is  frequent.  The  upper  chest  is 
depressed,  the  shoulders  thrown  forward,  the  neck  anterior,  the 
diaphragm  weakened,  and  its  central  tendon  shortened.  Other 
causes  of  weakened  tissues  are  improper  clothing,  especially  tight 
or  ill-fitting  corsets;  repeated  pregnancies  or  hydramnios;  ascites; 
sudden  loss  of  too  great  fat,  and  urgent  muscular  strain,  such  as 
heavy  lifting,  etc.  Certain  constitutional  diseases,  as  chlorosis, 
tuberculosis,  or  any  other  mal-nutrition  may  so  weaken  the  tissues 
as  to  permit  prolapse.  Neurasthenics,  epileptics,  and  others  with 
obscure  nervous  diseases  suffer  almost  constantly  from  enterop- 
tosis.  It  is  not  always  easy  to  determine  whether  the  ptosis  is  a 
cause  or  a  result  of  the  neurosis,  or  whether  both  neurosis  and 
ptosis  are  due  to  some  preexisting  cause. 

The  causes  of  too  great  visceral  weight  are  many :  constipation ; 
dilatation  of  the  stomach  and  of  the  colon ;  congestion  of  the  liver 
and  of  the   spleen  or  tumors   of  any   of  the   viscera.     Chronic 

68 


GASTRO-ENTEROPTOSIS  69 

inflammatory  processes  may  add  to  the  weight  of  the  viscera  and 
weaken  the  supporting  tissues  at  the  same  time. 

Diagnosis.  The  main  symptoms  are  abdominal  distention,  pain 
after  eating,  eructations  of  gas,  anorexia,  various  nervous  phenom- 
ena, weakness,  constipation,  and  in  some  cases  the  symptoms  of 
intestinal  stasis.  There  are  symptoms  of  a  more  or  less  marked 
neurasthenia  in  young  persons.  The  condition  may  be  present 
in  an  extreme  degree  without  causing  any  symptoms  in  some  per- 
sons, especially  in  women  after  "repeated  pregnancies. 

The  spine  shows  some  lesion  from  the  seventh  thoracic  to  the 
third  lumbar  vertebrae.  Rigidity  is  almost  constant.  A  general 
posterior  curve,  more  rarely  an  anterior  curve,  is  present.  The 
lower  ribs  are  always  depressed.  There  may  be  considerable  ten- 
derness of  the  lumbar  muscles.  Superficial  muscles  often  are  atonic, 
while  the  small  deep  spinal  muscles  are  irregularly  contracted. 

In  the  standing  position,  the  abdomen  protrudes  and  the  upper 
part  sinks  in ;  when  lying,  the  abdomen  shows  a  lateral  extension. 
Palpation  often  finds  a  ridge  lying  across  the  abdomen,  and  aortic 
pulsation  is  frequently  seen  and  felt. 

The  X-ray  gives  very  clear-cut  information  as  to  the  extent  of 
the  ptosis.  By  this  means  it  has  been  found  that  many  of  the 
intestinal  disturbances  are  associated  with  varying  degrees  of 
ptosis,  and  that  the  amount  of  perversion  is  much  greater  than  was 
formerly  supposed. 

The  urine  is  usually  loaded  with  indican,  and  various  related 
substances  resulting  from  putrefaction  may  be  present. 

The  blood  shows  the  effects  of  toxic  influences.  The  red  cells 
are  variously  deformed  and  are  sometimes  granular;  the  eosino- 
philes  are  slightly  increased;  the  polymorphonuclears  are  usually 
not  increased,  but  show  various  atypical  characteristics — irregular 
staining  reactions,  vacuolization  of  protoplasm  and  nucleus,  tend- 
ency to  fracture,  and  to  extrusion  of  the  nuclei.  On  the  warm  stage 
the  white  cells  move  sluggishly  and  cease  moving  quickly. 

In  middle-aged  and  young  persons  the  blood  pressure  is  usually 
lower  than  normal;  no  doubt  the  inefficiency  of  the  circulation  is 
one  factor  which,  by  adding  to  the  weight  of  the  organs,  causes 
the  ptosis.  On  the  other  hand,  the  ptosis,  by  disturbing  the  pres- 
sure relations  of  the  large  veins,  in  itself  tends  to  the  accumulation 
of  blood  in  the  mesenteric  vessels.  It  is  probable  that  the  low 
blood  pressure  is  both  a  cause  and  an  effect  of  the  ptosis. 

When  the  lower  half  of  the  abdomen  is  supported  by  the  hands 
or  by  a  wide  belt,  great  relief  is  felt.    (Glenard's  belt  test.) 

Treatment.  Correction  of  the  vertebral,  costal  and  innominate 
subluxations  is  of  first  importance.  General  abdominal  manipula- 
tions are  sometimes  indicated.  Manual  raising  pf  the  colon  may 
be  useful ;  a  proper  support  should  then  be  arranged  for  temporary 


70  THB  INTESTINES 

relief.  Treatments  should  be  given  every  day  or  every  two  days 
for  one  or  two  weeks,  then  once  or  twice  each  week  until  lesions 
are  fairly  well  corrected.  After  this,  the  patient  should  return 
for  examination  and  whatever  treatment  may  be  found  to  be  needed 
once  each  month  or  two  months,  for  a  year,  if  possible. 

There  are  several  diets  recommended.  The  all-cellulose  diet  of 
salad  vegetables  and  the  more  fibrous  of  the  cooked  vegetables, 
with  bran  bread,  aims  to  produce  bulk  and  thus  to  increase  per- 
istalsis. Thin  patients  receive  increased  amounts  of  fats,  must 
rest  after  meals,  and  be  made  to  gain  in  weight.  Obese  persons 
must  be  reduced  (see  obesity). 

The  farinaceous  diet  aims  to  diminish  the  bulk  of  the  food 
residue  as  much  as  possible.  The  low  proteid  diet  is  given  in 
order  to  reduce  putrefaction. 

Systematic  exercises  are  required  to  strengthen  the  weakened 
abdominal  and  other  muscles  and  establish  correct  posture  with 
correct  habits  of  breathing.  Having  the  patient  remain  in  the 
knee-chest  or  Trendelenburg  position  as  much  as  possible,  assists 
in  keeping  the  colon  in  place.  The  left  lateral,  or  Sims'  position, 
is  more  comfortable,  and  should  be  made  the  habitual  posture  for 
sleep  and  rest. 

"The  following  exercises  are  especially  beneficial  in  visceroptosis: 

"1.  Walking  on  the  hands  and  feet  with  the  knees  stiff.  This  is  a  rather 
awkward  movement  to  master  at  first  and  resembles  the  ambling  gait  of  a  bear. 
Its  advantage  is  very  evident  in  that  the  hips  are  so  much  higher  than  the 
shoulders.  This  permits  the  viscera  to  fall  upward  and  forward  and  utilizes 
gravity  to  help  correct  the  condition  it  has  assisted  to  produce. 

"2.  The  patient  lies  on  the  back  and  with  the  hands  on  the  hips,  elevates  the 
legs  to  a  perpendicular  position.  The  shoulders,  or  rather  the  dorsal  spine 
instead  of  the  hips,  are  made  to  support  the  column.  With  the  legs  in  this 
position,  a  twisting  motion  is  then  made  at  the  waist. 

"3.  Again  in  the  recumbent  position,  the  legs  are  raised  to  a  perpendicular 
position  first,  and  finally  the  body  is  flexed  until  the  feet  touch  the  floor  back  of 
the  patient's  head.  The  object  of  all  of  these  movements  is  very  evident.  They 
change  the  position  of  the  viscera,  tend  to  loosen  any  adhesions  that  might  be 
present  and  place  them  temporarily  at  least  in  a  more  normal  position." — W.  S. 
NichoU. 

"I  instruct  hjm  to  pull  the  abdomen  up  and  in,  every  night  and  morning  after 
retiring  and  before  arising,  when  lying  flat  upon  the  back  with  the  knees  flexed, 
by  placing  his  hands  in  the  iliac  fossae  and  raising  the  viscera.  The  assistance 
of  forced  exhalation  will  aid  materially.  This  exercise  should  be  kept  up  for 
four  or  five  minutes  or  until  the  patient  is  fatigued.  Then  at  other  times 
various  exercises,  such  as  bending  forward  and  sidewise,  may  be  used. 

"In  our  opinion,  an  exercise  of  greatest  aid  is  the  one  of  forced  exhalation. 
Have  the  patient  stand  erect,  breathing  normally,  then  pucker  the  lips  and  exhale 
gradually  and  forcefully  for  as  long  a  period  as  possible ;  this  brings  the  forced 
muscles  of  exhalation  into  use  and  domes  the  diaphragm,  giving  greater  upper 
abdominal  space.  When  exhalation  is  taking  place,  have  him  forcefully  elevate 
and  retract  abdomen.  This  exercise,  if  carried  out  several  times  a  day  and 
faithfully  continued  for  weeks,  will  have  a  pronounced  effect  in  replacing 
and  toning  the  viscera." — McConnell. 


DILATATION  71 

Mechanical  supports  may  act  beneficially  by  establishing  more 
correct  habits  of  breathing  and  posture,  and  by  holding  the  colon 
in  place.  These  give  the  patient  a  sense  of  relief,  and  this  is  a 
constant  reminder  for  him  to  elevate  and  retract  the  abdomen. 
Success  is  dependent  upon  the  patient's  cooperation.  Various  cor- 
sets and  supports  are  on  the  market  but  a  cotton  binder  answers 
very  well.     They  may  be  fitted  before  a  fluoroscope. 

The  elimination  of  drug  habits  is  one  of  the  important  factors 
in  treatment.  So  many  of  these  patients  have  been  habitually 
taking  cathartics,  and  have  so  great  a  horror  of  being  left  without 
them,  that  this  is  sometimes  one  of  the  hardest  things  to  do  in 
the  way  of  treatment — while  it  is  at  the  same  time  one  of  the 
most  important. 

Prognosis.  This  depends  upon  the  possibility  of  removing  the 
causes  of  the  condition,  upon  the  patient's  cooperation  in  the  way 
of  diet,  exercise,  etc.,  and  in  the  avoidance  of  purgative  drugs.  The 
spinal  and  lower  rib  lesions  being  corrected,  and  the  patient  giving 
even  moderate  obedience  to  the  instructidns,  the  prognosis  is  good 
for  practically  a  normal  abdomen,  when  there  has  been  no  actual 
destruction  of  the  supporting  tissues.  When  the  injury  is  too 
great,  or  when  old  age  or  congenital  weaknesses  of  the  patient 
prevent  a  good  prognosis,  a  suitable  support  must  be  worn  indef- 
initely. 

ACUTE  DILATATION 

(Enteroplegia) 

Acute  dilatation  is  an  expanded  portion  of  the  intestine  due  to  acute  obstruc- 
tion or  some  cause  producing  a  local  paresis,  or  to  a  congenital  weakness;  pro- 
ducing sornetimes  an  obstinate  constipation  and  in  other  cases  a  gaseous  dis- 
tention with  pain  and  colic. 

Etiology.  Acute  obstruction,  either  from  foreign  bodies,  adhesions,  vol- 
vulus, or  hernia  is  the  most  frequent  cause.  Of  the  general  causes  may  be  men- 
tioned local  or  systemic  infection ;  gastro-intestinal  paralysis  due  to  toxins 
circulating  in  the  blood  stream ;  trauma,  as  blows  on  the  abdomen  or  falls ;  gen- 
eral anaesthesia ;  nervous  influences ;  prolonged  handling  of  the  intestines  or 
their  exposure  to  the  air  during  abdominal  operations. 

Diagnosis.  The  symptoms  and  treatment  are  those  of  acute  obstruction 
and  are  considered  under  that  head. 

Gaseous  distention  of  the  intestinal  tract  may  cause  serious  embarrassment 
of  the  heart  and  lungs. 

CONGENITAL  IDIOPATHIC  DILATATION  OF  THE  COLON 

(Hirschsprung's  disease) 

This  is  an  anatomical  anomaly  of  congenital  origin  leading  to  a  looping  of 
the  colon.     Muscular  aplasia  leads  to  dilatation  and  valve   formation. 

Diagnosis.  The  condition  may  not  become  manifest  until-  adult  years. 
There  is  an  obstinate  constipation  with  now  and  then  attacks  of  diarrhea  when 
enormous  quantities  of  feces  are  voided.     There  is  a  history  of  a  distended 


72  THB  INTESTINES 

abdomen  from  early  infancy.  The  abdomen  may  become  enormously  distended. 
The  patient  becomes  emaciated  and  the  abdominal  veins  are  dilated.  The  recti 
muscles  may  be  separated.  There  is  no  abdominal  pain  or  tenderness  and 
vomiting  is  rare.  Borborygmus  is  often  very  loud.  The  urine  shows  increased 
indican. 

The  treatment  is  usually  surgical.  Relief  is  dependent  upon  the  physician's 
ability  to  establish  fairly  free  elimination.  This  condition  does  not  cause  death, 
but  renders  the  patient  more  susceptible  to  infections  and  the  ill-nourished  con- 
dition indicates  a  grave  prognosis. 


CHRONIC  DILATATION 

Chronic  dilatation  begins  insidiously  from  partial  obstruction  of  the  lumen 
from  cicatrizing  processes  of  the  walls,  new  growths,  compression  or  traction 
from  without  as  of  tumors,  healing  peritonitis,  or  coils  of  intestine  loaded  with 
feces.    The  symptoms  and  treatment  are  tho^e  of  chronic  partial  obstruction. 

ACUTE  INTESTINAL  OBSTRUCTION 

(Intestinal  stricture;  intestinal  occlusion;  ileus) 

Acute  obstruction  is  the  condition  resulting  from  various  causes 
whereby  peristalsis  cannot  move  the  fecal  mass  beyond  a  certain 
point ;  the  main  symptoms  are  about  the  same  in  all  forms,  varying 
somewhat  according  to  the  location  and  other  conditions  present  in 
different  cases. 

The  causes  are  grouped  under  eight  heads,  namely : 

1.  Accumulations  within  the  bowel  of  hardened  feces  (fecal 
impaction),  or  foreign  bodies  of  various  sorts  which  have  acci- 
dentally been  swallowed,  or  gall-stones. 

2.  Strictures  which  are  the  result  of  cancer,  ulceration,  cica- 
trices or  spasm.  Congenital  stricture  is  rare.  Atresia  ani  is  its 
most  frequent  representative,  though  congenital  strictures  are 
found  almost  at  any  point  of  the  intestinal  tract. 

3.  Pressure  against  the  bowel  from  peritoneal  adhesions, 
tumors,  or  abnormal  growths. 

4.  Strangulations  due  to  the  slipping  of  the  bowel  or  omentum 
through  the  openings  of  the  various  forms  of  hernia. 

5.  Invagination  or  intussusception  when  one  portion  of  the 
bowel  slips  over  another  part,  most  common  in  children. 

6.  Twisting,  rotation  or  volvulus. 

7.  Paretic  obstruction  is  due  to  paralysis  of  the  intestinal  mus- 
cle ;  the  fecal  mass  accumulates  and  dilates  this  portion,  thus  caus- 
ing the  obstruction.  It  may  result  from  inflammations,  from  the 
handling  of  the  bowel  during  abdominal  operations,  or  from  toxins, 
as  in  uremia,  typhoid  or  pneumonia;  or  from  referred  irritation, 
as  in  renal  colic,  gall-stones,  inflammation  of  the  testes,  injury  to 
the  spinal  column. 

8.  Spasmodic  contraction  of  the  circular  muscle  fibers  may 
simulate  ileus.     It  has  been  produced  experimentally  in  anesthe- 


OBSTRUCTION  ■  73 

tized  animals  by  suddenly  produced  bony  lesions,  by  handling  the 
intestine,  and  by  the  application  of  heat,  electricity  or  chemical 
irritants  directly  to  the  intestinal  wall. 

Of  these  strangulation  is  the  most  frequent  in  adults;  volvulus  in  children. 
Meckel's  diverticulum  is  a  remnant  of  the  omphalo-mesenteric  duct,  an  embry- 
onic structure  which  -should  be  atrophied  in  very  early  life.  When  it  persists, 
as  occasionally  happens,  it  usually  has  its  peripheral  (navel)  end  free,  but  some- 
times this  remains  attached  to  the  abdominal  wall,  making  a  loop  through  which 
the  intestine  may  pass  and  become  strangulated.  Loops  of  intestine  may  also 
pass  between  adhesions  of  various  classes,  as  those  at  the  site  of  old  inflam- 
matory processes ;  or  around  the  pedicle  or  a  tumor,  or  into  peritoneal  pouches 
in  a  number  of  different  ways. 

Hernia  is  the  condition  which  occurs  when  a  loop  of  intestine  passes  into 
any  opening  or  pouch — in  external  hernia  the  intestine  protrudes  without  the 
abdominal  wall ;  in  internal  hernia  the  loop  passes  into  any  of  the  narrow  passes 
already  mentioned,  or  others  of  similar  relationships. 

At  any  time,  a  hernia  may  become  strangulated.  In  such  a  case  the  diagnosis 
is  easy  for  external  hernia,  obviously,  but  may  be  extremely  difficult  in  internal 
hernia. 

The  cause  of  death  in  acute  total  obstruction  seems  to  be  the  presence  of 
some  poisonous  substance  elaborated  in  the  small  intestine,  and  normally  passed 
into  thd  lumen  of  the  bowel.  In  total  obstruction,  this  substance  is  absorbed  into 
the  blood,  and  the  whole  body  poisoned.  When  even  slight  intestinal  movements 
occur,  this  poisoning  does  not  appear,  even  though  the  retention  may  appear  to 
be  complete.  When  no  defecation  occurs  for  two  weeks  or  even  more,  from 
other  causes,  the  symptoms  may  be  comparatively  slight;  but  when  there  is 
total  obstruction  for  as  many  days  the  symptoms  are  severe  and  death  seems  to 
be  at  the  door;  life  is  rarely  maintained  more  than  a  week  after  the  condition 
is  recognized,  unless  rehef  is  secured.  The  higher  the  obstruction,  the  more 
speedily  death  occurs. 

Diagnosis.    The  symptoms  are  almost  pathognomonic. 

Pain  sets  in  abruptly;  it  is  usually  intense,  at  first  paroxysmal, 
then  becoming  continuous;  it  is  located  in  the  middle  line  above 
the  umbilicus  if  the  obstruction  is  in  the  small  intestine;  and 
descends  into  the  hypogastrium  if  the  large  intestine  is  involved. 
Constipation  is  absolute,  though  feces  may  be  passed  or  removed 
by  enemas  from  the  bowel  below  the  obstruction.  Vomiting  is 
first  of  the  stomach  contents,  later  of  bile-stained  material,  finally 
of  brownish  fluid  with  a  fecal  odor.  Abdominal  distention  is  uni- 
form unless  the  obstruction  is  high  up  but  the  flanks  do  not  bulge. 
Paroxysmal  peristaltic  movements  are  visible  through  the  abdom- 
inal wall  around  the  umbilicus  if  the  obstruction  is  in  the  small 
intestine ;  if  low  in  the  colon,  peristalsis  is  seen  along  its  line,  the 
waves  moving  from  right  to  left. 

Tumor  may  sometimes  be  felt  in  malignant  stricture.  In  intus- 
susception, a  sausage-shaped  tumor  may  be  found  in  the  right  iliac 
fossa  or  in  the  line  of  the  colon. 

Occasionally  in  infants  the  obstruction  and  the  ileo-colic  valve 
may  be  felt  upon  rectal  examination.  Blood  may  be  passed  by 
bowel  and  tenesmus  is  often  marked.  The  general  symptoms  are 
those  of  collapse,  indicated  by  pinched  face,   cold  sweat,  small 


74  THE  INTESTINES 

rapid  pulse,  dry  tongue,  scanty  urine,  great  thirst,  and  either  nor- 
mal or  subnormal  temperature.  Death  from  asthenia  or  peritonitis 
occurs  from  the  third  to  the  sixth  day  if  relief  is  not  secured. 

The  blood  changes  are  marked.  Leucocytes  rise  rapidly  to 
about  16,000  per  c.mm.  when  the  bowel  is  partially  obstructed ;  to 
20,000  with  complete  occlusion.  When  the  leucocytes  rise  to  over 
20,000  within  first  24  hours,  the  chances  are  in  favor  of  gangrene. 
Leucocytosis  of  more  than  80,000  has  been  reported. 

The  X-ray  gives  accurate  information  concerning  the  location 
of  the  obstruction,  and  often  of  the  nature  of  the  lesion. 

Examinations  per  rectum  et  vaginam  and  the  exploration  of 
hernial  orifices  may  g^ve  useful  information.  Fecal  vomiting  occurs 
earlier  in  the  higher  obstruction. 

Large  injections  of  water  may  determine  the  capacity  of  the 
colon  and  hence  something  of  the  site.  This  is  best  given  in  the 
knee-chest  position,  the  Sims  position,  or  with  the  patient's  hips 
elevated  and  the  thighs  flexed  upon  the  abdomen.  Such  an  injec- 
tion may  straighten  out  intestinal  distortions  or  help  to  push  a 
tumor,  etc.,  into  better  position,  thus  removing,  temporarily  at 
least,  the  obstruction. 

Treatment.  Some  therapeutic  methods  are  common  to  all  forms 
of  obstruction;  others  depend  upon  the  nature  of  the  obstruction. 

A  few  cases  will  respond  to  very  careful  work  with  the  patient 
in  the  knee-chest  position. 

It  is  always  best  to  have  an  experienced  surgeon  in  consultation 
if  possible. 

In  all  cases  purgative  or  emetic  or  analgesic  drugs  are  abso- 
lutely contraindicated.  Death  may  be  hastened,  or  recovery  pre- 
vented after  the  removal  of  the  cause  of  the  obstruction,  by  the 
early  use  of  the  so-called  "home  remedies,"  which  may  include 
almost  anything  from  castor  to  croton  oil  and  blue  mass. .  Enemas 
should  be  used  to  cleanse  the  lower  bowel.  Ice  in  the  mouth 
relieves  thirst;  the  water  should  not  be  swallowed.  Heat  over  the 
abdomen  relaxes  the  muscular  walls,  relieves  pain,  and  sometimes 
gives  sleep  and  rest.    Gastric  lavage  may  be  used  freely. 

Such  spinal  treatments  as  are  indicated  on  examination  often 
give  marked  relief.  Reflex  muscular  contractions  are  found  in  the 
areas  of  spinal  muscles  which  are  in  closest  central  connection  with 
the  sensory  nerves  from  the  intestinal  areas  of  greatest  irritation, 
but  do  not  necessarily  refer  to  the  area  of  obstruction.  The  relax- 
ation of  these  muscles  gives  comfort.  After  the  removal  of  the 
cause  the  spinal  treatment  hastens  recovery. 

In  surgical  cases,  the  earlier  the  operation  the  better  the  prog- 
nosis. It  is  very  necessary  to  save  time  in  such  c|ises,  even  at  the 
expense  of  some  weariness  to  the  patient.. 


■   OBSTRUCTION  75 

Other  methods  of  treatment  apply  chiefly  to  special  forms  of 
obstruction. 

Fecal  impaction  is  diagnosed  from  the  other  obstructions  by 
the  gradual  onset,  the  absence  of  hernias,  and  the  presence  of  an 
irregular  "doughy"  mass  following  the  line  of  the  colon. 

Treatment.  Stop  all  purgatives — most  of  these  patients  are  in 
the  habit  of  using  them.  If  the  rectum  cannot  be  cleansed  by 
enemas,  the  rectal  scoop  or  manual  removal  must  be  used.  If 
the  mass  is  higher,  enemas  of  warm  oil  will  help  soften  the  mass 
so  it  can  be  removed  by  using  plain  warm  water,  or  soap  suds. 
In  some  cases,  surgery  may  be  necessary.  Avoid  manipulation 
until  the  masses  have  been  softened ;  the  dry,  hard,  adherent  masses 
may  injure  the  intestinal  walls. 

The  prognosis  is  favorable  for  recovery.  Recurrence  is  to  be 
expected  unless  the  original  cause  is  removed. 

Strangulated  hernia  is  the  form  most  often  found  needing 
urgent  relief.  The  predisposing  causes  are  sudden,  heavy  lifting; 
constipation,  and  rapid  fat  formation. 

The  symptoms  are  sudden  pain  in  and  around  the  hernia; 
violent  and  colicky  pains  around  the  umbilicus ;  the  tumor  becomes 
larger,  is  tender,  painful  and  dull  on  percussion  and  without 
impulse  on  coughing;  the  intestinal  wall  becomes  edematous; 
uncontrollable  vomiting  comes  on  early ;  prostration  increases  to 
collapse ;  the  pains  become  more  violent ;  the  pulse  is  small,  irreg- 
ular, rapid  and  may  be  very  weak;  the  temperature  is  normal  of 
subnormal  (sometimes  a  slight  fever  is  present  at  first)  ;  and  the 
Hippocratic  facies  is  characteristic.  When  gangrene  begins,  the 
vomiting  ceases,  pain  abates,  hiccoughs  appear,  the  pulse  becomes 
very  frequent,  feeble,  and  intermittent;  collapse  deepens  and 
delirium  is  common. 

Treatment.  The  first  thing  is  to  attempt  reduction.  Put  the 
patient  upon  his  back  with  the  hips  elevated,  the  thighs  flexed  upon 
the  abdomen,  rotate  the  leg  upon  the  affected  side  slightly  inward 
to  relax  the  tissues  around  the  inguinal  rings.  Apply  taxis  of 
gentle  manipulation  using  such  methods  as  the  location  indicates 
to  replace  the  bowel  (or  omentum).  Reduction  is  evidenced  by 
the  sudden  slip  from  the  hand  or  an  audible  gurgle  as  the  loop 
enters  the  abdomen.  Taxis  must  never  be  employed  in  cases  of 
great  acuteness ;  in  cases  where  the  strangulation  has  existed  for 
several  days;  in  cases  known  to  have  been  previously  irreducible; 
in  cases  with  stercoraceous  vomiting,  or  in  cases  with  inflamed  or 
gangrenous  hernia.  If  taxis  fails,  operate  as  speedily  as  possible, 
first  trying  reduction  under  ether. 

After  reduction,  put  the  patient  to  bed ;  apply  a  pad  and  band- 
age; allow  no  food  until  vomiting  ceases,  allowing  a  little  hot 


Id  THB  INTESTINES 

water  for  24  hours,  and  keep  on  liquid  food  for  several  days.  At 
the  end  of  the  first  week  begin  to  give  solid  food. 

If  the  bowels  do  not  move  after  four  or  five  days,  a  small 
enema  may  be  gently  given.  This  may  be  repeated  daily  until 
defecation  occurs  normally  and  the  regular  diet  is  permitted. 

Before  leaving  the  bed,  a  truss  should  be  fitted.  The  best 
treatment  for  hernia  is  surgical  repair,  unless  there  is  some  contra- 
indication. 

Prognosis.  The  prognosis  must  be  guarded  until  the  normal 
digestion  has  been  reestablished. 

In  intussusception  a  history  of  purgation,  diarrhea  or  other 
form  of  intestinal  irritation,  or  of  precedent  symptoms  indicating 
ulcers  or  polyps  will  probably  be  found.  The  patient  is  usually 
a  child. 

Occasionally  the  invaginated  portion  may  be  sloughed  off,  the 
upper  edge  of  the  rings  adhere,  and  the  patient  may  recover  spon- 
taneously by  this  natural  surgery.  Such  a  termination  must  be 
very  rare,  however.  The  slipping  of  the  ileum  into  the  colon  is 
perhaps  the  most  common  location. 

Treatment.  The  patient  should  be  placed  in  the  Trendelenburg, 
the  Sims,  or  the  knee-chest  position.  Warm  oil  or  soapy  water 
should  be  slowly  injected  into  the  rectum,  under  low  pressure, 
while  gentle  manipulations  are  given  over  the  abdomen.  An  assis- 
tant may  give  deep,  steady  pressure  over  the  spinal  regions  of 
greatest  muscular  tension ;  this  lessens  the  pain  of  the  manipula- 
tions. If  there  is  difficulty  in  securing  the  reduction,  the  pressure 
of  the  injecting  oil  or  water  is  increased,  hot  cloths  applied  over 
the  abdomen  around  the  site  of  the  manipulations,  and  the  position 
of  the  patient  changed.  After  reduction  has  been  secured,  the 
patient  should  be  kept  in  bed  on  a  liquid  diet,  for  several  days. 

If  reduction  is  impossible,  surgical  aid  should  be  secured 
speedily — certainly  within  twenty-four  hours  if  possible.  The 
longer  the  operation  is  delayed  the  less  hopeful  is  the  prognosis. 

Vovulus  is  a  condition  thought  to  be  caused  by  excessive 
peristalsis  caused  by  unequal  filling  of  the  coils  or  by  contusions 
especially  acting  upon  intestines  with  an  abnormally  long  mesen- 
tery, thus  producing  a  more  or  less  completely  obstructed  bowel  by 
a  twist  or  kink  about  its  long  axis.  One  half  of  the  cases  occur  in 
the  sigmoid  flexure.  Males  between  thirty  and  forty  years  are 
most  often  afifected. 

Treatment.  Direct  treatment  to  the  affected  area  is  here  indi- 
cated but  it  must  be  carefully  done.  Spinal  treatment  controls 
the  blood  and  nerve  supply,  lessens  the  pain,  and  tends  to  estab- 
lish a  normal  peristalsis  and  secretion  throughout  the  intestinal 
region. 


OBSTRUCTION      ~  71 

Surgery  is  immediately  necessary  unless  the  condition  can  be 
removed  within  a  few  hours. 

The  prognosis  is  grave,  as  in  all  forms  of  obstruction.  Recov- 
eries occur. 

Strictures  are  almost  invariably  surgical,  and  are  speedily  fatal 
unless  removed.  Occasionally  such  conditions  can  be  temporarily 
relieved  by  manipulation  and  enemas,  but  these  methods  are  rarely 
of  permanent  value.  The  removal  of  the  injured  section  of  the 
intestine  is  the  usual  surgical  procedure.  The  prognosis  in  all 
cases  depends  upon  the  nature  of  the  cause. 

Peritoneal  adhesions  are  sometimes  stretched  by  manipulations 
applied  directly  over  the  adherent  bands,  thus  relieving  the  ten- 
sion. It  is  necessary  to  use  great  care,  lest  inflammatory  reaction 
and  the  adhesions  be  thereby  increased.  In  such  cases  treatment 
must  be  continued  at  rather  long  intervals  for  months,  in  order  to 
prevent  recurrences.  When  the  condition  is  complicated  by  tumors, 
these  may  or  may  not  be  removed,  according  to  the  benignancy, 
location,  and  size  of  the  tumor  in  each  case,  and  the  physical  condi- 
tion of  the  patient. 

Paretic  Obstruction.  When  a  segment  of  the  intestinal  wall 
has  become  paralyzed  the  best  treatment  is  rest.  Daily  ene- 
mas for  the  removal  of  the  lower  feces,  sometimes  rectal  feeding, 
gastric  lavage,  alternate  hot  and  cold  applications  to  the  abdom- 
inal wall,  and  the  spinal  corrections  indicated  on  examination,  give 
best  results.  If  the  symptoms  do  not  abate,  the  removal  of  the 
injured  segment  of  the  intestine  is  indicated. 

Prognosis.  In  all  cases  of  intestinal  obstruction  the  prognosis 
must  be  guarded,  not  only  for  recovery  from  the  acute  attack  but 
also  for  recurrence. 

Chronic  obstruction  is  that  condition  of  gradually  increasing 
closure  of  the  intestinal  canal  most  commonly  due  to  malignant 
growths.  Gradually  increasing  and  hardening  fecal  masses,  and 
the  slow  contraction  of  cicatricial  bands  are  also  etiological  factors. 
Enteroliths  and  foreign  bodies  are  rarely  causes  of  chronic  obstruc- 
tion. 

Diagnosis.  There  is  a  history  of  gradually  increasing  constipa- 
tion alternating  with  diarrhea  perhaps,  abdominal  pain  and  disten- 
tion and  general  failure  of  the  health.  There  may  be  recurrent 
threatenings  of  acute  obstruction  until  finally  there  is  complete 
occlusion,  symptoms  of  acute  obstruction,  and  death. 

The  feces  are  narrowed  in  character,  of  pipe-stem  shape,  flat- 
tened like  a  tapeworm,  or  composed  of  small,  rounded  masses  like 
sheep's  dung,  frequently  smeared  on  the  surface  with  blood  and 
pus.     Portions  of  tumors  are  sometimes  found. 


78  THU  INTESTINES 

Abdominal  palpation  and  inspection,  with  the  rectal  and  vaginal 
examinations,  may  locate  the  growth,  adhesive  bands,  or  fecal 
masses. 

X-ray,  after  giving  bismuth  or  other  suitable  enemas,  shows 
the  place  of  interference;  the  nature  of  the  cause  of  the  occlusion 
may  often  be  inferred  from  the  X-ray  plate. 

Treatment.  Most  thorough  and  careful  examination  must  be 
made  to  determine  the  location  of  the  growth.  Surgery  offers  the 
best  hope  for  permanent  relief.  If  non-operable,  careful  regulation 
of  the  diet,  with  enemas  and  spinal  work  to  alleviate  the  pain,  is 
palliative.  Fecal  concretions  must  be  softened,  sometimes  by  days 
of  successive  oil,  saline,  and  soap  enemas. 

Adhesive  bands  may  sometimes  be  benefited  by  stretching. 
Injury  to  the  intestines  must  be  avoided.  Surgery  for  these  is  of 
dubious  value;  if  the  bands  can  be  cut  without  the  formation  of 
later  adhesions,  this  leads  to  permanent  recovery  from  the  con- 
dition. Unfortunately,  such  operations  are  too  often  followed  by 
the  formation  of  other  bands,  perhaps  more  harmful. 

Prognosis.  This  depends  upon  the  possibility  of  removing  the 
obstruction.  If  this  cannot  be  removed,  death  is  quickly  inevitable ; 
if  the  obstruction  can  be  removed  completely,  recovery  is  speedy 
and  practically  complete.  Between  these  extremes  lie  all  grada- 
tions of  prognosis. 

INTESTINAL  TUMORS.  Carcinoma  is  the  most  important  intestinal 
neoplasm.  The  symptoms  are  those  of  chronic  obstruction,  with  cachexia. 
Rarely  the  obstruction  may  first  appear  in  the  acute  form;  in  other  cases  the 
first  symptoms  are  those  of  perforation. 

Rectal  tumors  may  be  either  adenoma  or  epithelioma.  They  are  often 
branched  and  of  delicate  structure,  so  that  masses  of  the  growth  may  be  passed 
with  the  feces ;  bleeding  is  apt  to  occur. 

In  the  duodenum,  the  ileo-cecal  region,  and  the  rectum  polypoid  growths 
may  occur.  These  probably  originate  from  shreds  left  from  old  inflammatory 
areas;  they  are  composed  chiefly  of  mucous  glands  in  a  connective  tissue 'net- 
work. Their  growth  may  result  in  various  types  of  obstruction.  When  they 
are  so  attached  as  to  act  like  a  ball  valve,  the  resulting  symptoms  may  be  most 
confusing.  In  the  sigmoid  area  the  symptoms  may  be  those  of  a  spastic  colitis. 
Care  should  be  taken  to  avoid  confusing  colitis  and  a  possible  diverticulum. 

Connective  tissue  tumors  usually  grow  into  the  peritoneal  cavity,  and  cause 
little  or  no  disturbance.  Rarely,  tumors  either  within  or  without  the  intestinal 
cavity  may  cause  irregular  symptoms  of  intestinal  irritation,  with  colicky  pains 
and  griping,  but  with  no  evidences  of  organic  disease.  Such  cases  are  apt  to 
be  diagnosed  as  intestinal  neuroses. 

Many  of  these  are  recognized  or  suspected  only  post  mortem.  Those  which 
cause  occlusion  can  be  treated  surgically  if  at  all. 


CHAPTER  VII 
ENTERITIS  OF  CHILDREN 

The  intestinal  inflammations  of  children  have  practically  always 
a  more  or  less  pronounced  "nervous"  basis;  rarely  a  purely  "nerv- 
ous" diarrhea  is  present,  and  this  does  not  result  in  true  enteritis 
unless  the  imperfectly  digested  food  acts  as  an  inflammatory  agent. 
Considering  the  nervous  element  always  present,  three  classes  of 
acute  infantile  enteritis  are  to  be  recognized :  irritative,  fermental, 
and  infectious.     These  differ  in  etiology,  diagnosis  and  treatment. 

The  possibility  that  vomiting  and  diarrhea  may  be  symptoms 
of  disease  of  the  central  nervous  system  or  of  the  kidneys  must 
not  be  forgotten.  The  examination  of  the  pupils  and  of  the  various 
reflexes  should  eliminate  the  first;  the  microscopical  examination 
and  chemical  tests  of  the  urine  should  eliminate  the  second  possi- 
bility. 

ACUTE  IRRITATIVE  ENTERITIS  OF  CHILDREN 

(Nervous  indigestion;  intestinal  intoxication;  acute  dyspeptic  diarrhea) 

This  is  a  catarrhal  enteritis  in  children,  due  to  improper  intes- 
tinal content,  and  characterized  by  vomiting,  colic,  and  diarrhea. 
This  form  is  usually  comparatively  mild  and  is  self-limiting.  The 
diarrhea  and  vomiting  eliminate  the  offending  material,  and  recov- 
ery usually  occurs  spontaneously  within  two  days.  When  the 
etiological  factors  persist,  and  in  certain  other  circumstances,  the 
disease  passes  into  more  serious  forms. 

Etiology.  The  predisposing  causes  include  poor  nutrition  and 
habitual  use  of  improper  foods ;  teething ;  insanitary  surroundings ; 
previous  attacks ;  climatic  changes ;  nervous  irritability,  due  to 
bad  inheritance  and  to  the  presence  of  irritable  mothers  and  other 
adults.  Bony  lesions,  including  the  spinal  column  from  the  mid- 
thoracic  to  the  coccyx,  may  be  either  primary  or  secondary.  The 
lower  thoracic  and  lumbar  area  are  most  often  involved.  Lower 
rib  lesions  are  usually  secondary. 

Exciting  causes  include  the  use  of  improper  food,  food  given  at 
improper  times,  or  of  too  great  quantity ;  sudden  change  of  diet ; 
sudden  change  in  temperature;  emotional  storms;  fatigue;  loss  of 
sleep — anything  which  disturbs  either  the  quality  of  the  intestinal 
contents  or  the  physiological  balance  of  the  intestinal  nerve  centers. 
An  important  factor  often  neglected  is  the  spinal  shock  resulting 
from  the  falls  and  strains  to  which  children  learning  to  walk  and 
those  playing  with  one  another  are  especially  subject. 

79 


80  ENTERITIS  OF  CHILDREN 

Diagnosis.  The  trouble  begins  abruptly  with  nausea  and  vom- 
iting several  hours  or  days  after  the  disturbing  diet.  Rumbling 
noises  in  the  abdomen  usually  precede  the  evacuations  and  consid- 
erable gas  is  passed.  There  are  colicky  pains,  moderate  tymf 
panites,  and  diarrhea.  The  child  is  irritable,  sleeps  poorly,  and 
convulsions  may  occur.  The  fever  is  rarely  high,  102°  to  105°  F. 
in  infants,  103°  F.  in  older  children.  The  pulse  is  rapid  and  pros- 
tration is  marked  in  the  very  young  or  weak  child.  Stools  are  four 
to  twelve  or  more  in  twenty-four  hours,  at  first  normal  in  color 
and  odor  for  the  diet  used  and  the  age  of  the  child.  Later  they  are 
liquid  in  character  and  contain  undigested  whitish  masses.  No 
blood  or  excessive  mucus  is  present  in  the  early  stages  unless  there 
had  been  extreme  irritation  in  the  diet.  There  is  no  persistent 
fever,  no  toxemia.  The  child  does  not  look  sick.  In  prolonged 
cases  there  may  be  seen  excessive  mucus  and  flecks  of  blood  due 
to  a  subsequent  colitis.  Convulsions  may  precede  or  accompany 
the  diarrhea. 

Treatment.  This  depends  much  upon  the  age  of  the  patient  but 
the  general  principles  are  the  same.  Empty  the  bowels  as  soon 
as  possible  by  enema  and  gentle  manipulation.  Gastric  lavage  is 
useful  during  the  early  stages  or  if  vomiting  persists. 

Withhold  food,  giving  boiled  water,  whey,  or  albumen  water 
for  thirst,  one  to  four  teaspoonfuls  at  a  time  for  an  infant  and  at 
short  intervals.  If  possible,  give  as  much  boiled  water,  or  other 
liquid  as  mentioned,  as  would  have  been  given  of  both  food  and 
water  during  the  same  period  of  health.  If  cool  water  causes 
vomiting,  give  it  quite  warm,  as  much  as  can  be  taken,  in  order  to 
serve  as  lavage  if  not  retained.  It  must  be  remembered  that  the 
diarrhea  removes  very  large  amounts  of  water  from  the  circulation ; 
this  must  be  restored  as  rapidly  as  possible. 

When  water  is  persistently  refused,  the  enema  may  serve. 
After  the  colon  seems  emptied  of  fecal  material,  a  quarter  to  half 
pint  of  normal  salt  solution^ may  be  injected,  and  this  will  be 
retained  for  some  time,  especially  if  the  buttocks  are  raised  slightly. 
A  variable  amount  of  this  water  will  be  absorbed  into  the  general 
circulation. 

Frequent  bathing  for  cleanliness  and  the  reduction  of  tempera- 
ture is  necessary.  A  tub  at  100°  F.  gradually  reduced,  is  the  best, 
using  gentle  friction  during  the  five  to  twenty  minutes  of  the  bath. 
Fresh  air  is  essential ;  as  soon  as  the  child  can  be  moved,  take  him 
to  the  seashore  or  any  place  where  he  can  have  the  best  food 
and  air. 

The  clothing  should  consist  of  a  single  loose  garment.  The 
child  should  be  protected  from  sudden  changes  of  the  temperature 
by  suitable  coverings.     Napkins  should  be  removed  as  soon  as 


IRRITATIVE  ENTERITIS  81 

soiled,  taken  from  the  room  and  placed  in  a  disinfecting  solution  or 
burned.  Absolute  cleanliness  of  the  buttocks  and  genitalia  with 
the  free  use  of  some  absorbent  powder  as  starch  and  boric  acid 
will  prevent  excoriations. 

Marked  tension  and  hypersensitiveness  in  the  spinal  areas,  espe- 
cially through  the  mid-thoracic  and  lower  thoracic  region  are  con- 
stant; these  recur,  and  must  be  relieved  as  frequently.  Bony 
lesions  may  result  from  these  reflex  contractions.  Correction  of 
such  perversions  as  they  are  found  hastens  recovery  and  lessens 
the  danger  of  recurrences  under  slight  provocation. 

Convalescence  is  usually  rapid  -in  uncomplicated  cases.  Care 
is  necessary  to  prevent  too  sudden  a  return  to  ordinary  diet. 

"In  breast-fed  babies,  give  boiled  water  during  the  period  of  withholding 
food.  Then  resume  breast  feeding  and  dilute  by  giving  immediately  before  nurs- 
ing a  mixture  of  one  teaspoonful  each  of  boiled  water  and  linie  water.  Allow 
nursing  five  minutes  first  time,  ten  minutes  the  second  time,  and  then  back  to 
normal.  In  bottle-fed  babies,  withhold  food  twenty-four  to  forty-eight  hours, 
then  return  to  former  diet,  if  it  had  previously  agreed  with  it,  by  giving  at 
first  one  fourth  strength,  then  one  half,  then  full  strength  feeding.  If  there 
is  any  indication  gf  an  ileo-colitis  present,  as  excessive  mucus  and  flecks  of 
blood,  give  a  daily  irrigation  of  the  colon." — J.  H.  Long. 

"Some  nervous  children  have  convulsions.  When  these  occur,  wrap  them 
in  blankets  wrung  out  of  hot  water  or  dip  the  child  into  tub  of  hot  water  with 
cold  cloth  on  head.  However,  osteopathic  treatment  to  cervical  region  usually 
takes  care  of  this  condition,  unless  in  very  severe  cases. 

"One  of  the  most  trying  symptoms  in  these  simple  diarrheas  is  colic  and 
griping  pains.  It  is  my  experience  that  no  method  of  treatment  so  quickly 
relieves  it  as  osteopathic  treatment  to  spine  from  eighth  to  tenth  dorsal  and 
gentle  deep  pressure  over  solar  plexus.  A  hot  water  bottle  may  be  applied  to 
abdomen  and  epigastrium  following  treatment." — Nettie  M.  Hurd. 

For  older  children  the  diet  is  much  like  that  of  infants  at  first. 
Later,  meat  broths,  eggs,  dried  bread  and  milk  may  be  given 
cautiously.  Cereals,  vegetables  and  fruit  should  usually  be  with- 
held for  some  time.  The  fruit  and  vegetable  juices  may  then  be 
given,  and  the  regular  normal  diet  resumed  within  a  week  or  ten 
days. 

Prognosis.  In  infants  all  diarrheas  should  be  regarded  with 
suspicion,  though  the  simple  forms  usually  pass  away,  as  in  older 
children,  within  a  few  days.  Each  attack  predisposes  to  later 
attacks,  more  severe,  with  less  marked  causes.  During  an  attack 
the  child  is  more  than  usually  susceptible  to  infections,  especially 
of  the  intestinal  tract. 

Prophylaxis.  The  education  of  mothers  in  regard  to  the  feeding 
and  care  of  infants  and  older  children,  proper  milk  inspection  and 
the  enforcement  of  sanitary  laws,  and  the  occasional  osteopathic 
examination  of  children  would  practically  remove  these  forms  of 
enteritis  from  the  world. 


82  ENTERITIS  OF  CHILDREN 

ACUTE  FERMENTAL  ENTERITIS  OF  CHILDREN 

(Choleriform  diarrhea;  summer  complaint;  cholera  infantum) 

Fermental  enteritis  is  an  acute  inflammation  of  the  stomach 
and  intestines,  characterized  by  severe  colic,  vomiting,  purging, 
early  high  fever  of  short  duration  and  marked  prostration. 

Etiology.  Hot  weather,  especially  w^ith  high  humidity;  too 
warm  clothing;  teething;  improper  food,  especially  bad  milk,  bad 
meat,  or  foods  unsuitable  for  babies ;  and  imperfect  hygiene  in 
general,  are  predisposing  factors.  Bony  lesions  are  more  variable 
than  in  the  simpler  diarrheas.  Lesions  of  the  cervical  vertebrae 
are  rather  more  frequent.  ,    • 

The  exciting  causes  are  usually  dietetic  errors.  Sometimes  no 
efficient  exciting  cause  can  be  found;  these  cases  usually  occur  in 
children  whose  hygienic  and  dietetic  conditions  are  bad. 

"To  understand  the  condition  present  it  is  necessary  to  recall  the  kinds  of 
bacteria  normally  present  in  the  intestines  and  their  actions.  We  find  present 
in  the  intestines,  first,  the  obligate  fermentative  organisms  which  live  in  a  car- 
bohydrate media  and  form  products  which  are  nontoxic;  second,  the  obligate 
putrefactive  organisms,  which  must  have  a  proteid  media  in  which  to  live  and 
in  the  absence  of  which  they  soon  die  out.  They  act  upon  the  proteids,  splitting 
them,  and  form  products  which  are  toxic;  third,  the  facultative  fermentative 
organisms,  which  are  normally  present  and  as  long  as  there  is  a  carbo-hydrate 
media  present  they  will  live  on  it  and  the  products  formed  are  nontoxic,  but 
when  the  carbo-hydrates  are  deficient,  or  when  there  are  abnormal  conditions 
present  in  the  intestines  they  act  upon  the  proteids  and  produce  toxic  substances. 
In  cases  where  there  is  simply  indigestion,  or  under  influence  of  a  change  in 
the  digestive  powers,  or  abnormal  chemical  contents,  or  by  feeding  excessive 
proteids,  the  obligate  fermentative  organisms  are  inhibited  in  their  growth  and 
the  facultative  fermentative  bacteria  then  act  upon  the  proteids  and  produce 
substances  toxic.  This  type  of  diarrhea  is  the  most  fatal  and  in  some  cases 
the  toxemia  is  overwhelming,  the  child  dying  within  the  first  twenty-four  hours." 
-J.  H.  Long. 

Diagnosis.  The  onset  may  be  sudden  or  preceded  by  intestinal 
disturbance,  then  vomiting  and  purging  occur  with  severe  abdom- 
inal pain  and  high  fever,  102°  to  106°  F.  (the  temperature  should  be 
taken  by  rectum  as  the  body  surface  is  cold).  The  pulse  is  rapid 
(130  to  160)  and  feeble;  intense  thirst  may  be  a  marked  feature; 
distressing  retching  follows,  and  rapid  wasting  may  be  apparent 
within  a  few  hours.  The  appearance  is  noticeable  and  character- 
istic. The  body  shrinks;  the  eyes  are  sunken  and  partly  closed; 
the  mouth  partly  open;  the  lips  are  dry,  cracked,  and  bleeding; 
and  the  skin  a  peculiar  ashy  pallor.  At  first  the  child  is  irritable 
and  restless,  but  soon  becomes  semi-comatose ;  the  pulse  becomes 
more  and  more  rapid  and  feeble ;  the  body-surface  cold  and  clammy. 
The  tongue  is  found  heavily  coated.  The  spinal  muscles  are  found 
heavily  contracted.  There  may  be  bony  mal-adjustments.  The 
stools  are,  at  first,  fecal,  brown  or  yellow  and  very  offensive,  soon 
becoming  thin,  alkaline,   serous,   or  watery   and   leaving  a  faint 


FBRMENTAL  ENTERITIS  83 

greenish  or  yellowish  stain  on  the  napkin.  They  number  from 
ten  to  thirty  a  day  and  possess  a  musty  odor.  The  urine  is  dimin- 
ished or  suppressed.  The  pupils  contract  but  are  unresponsive  to 
light;  the  stupor  deepens;  the  fingers  are  clutched;  there  may  be 
convulsions;  the  head  may  be  retracted;  respirations  may  be  of 
the  Cheyne-Stokes  type;  these  last  form  the  "hydrencephaloid" 
symptoms. 

The  termination  may  be  by  death  from  profound  exhaustion  or 
convulsions.  In  recovery,  the  symptoms  gradually  diminish  and 
the  disease  passes  into  a  slow,  tedious  convalescence. 

Treatment.  Careful  and  thorough  spinal  manipulation,  relaxing 
and  correcting  as  is  indicated  in  the  individual  case,  assists  in  elim- 
inating the  poisons  and  in  restoring  the  normkl  functions.  Empty 
the  stomach  and  bowels  by  washing  the  stomach  and  by  irrigating 
the  bowels.  Supply  fluid  to  the  blood  if  necessary,  to  make  up  for 
the  very  great  drain  of  the  discharges,  by  subcutaneous  injection 
of  at  least  a  half  pint  of  warm  normal  saline  solution  every  twelve 
hours.  If  the  case  is  not  so  serious,  the  Murphy  "drop"  may  be 
sufficient. 

Reduce  the  temperature  by  tepid  sponging  and  by  the  ice  cap 
to  the  head.  Deep,  steady  pressure  in  the  suboccipital  fossa  may 
reduce  the  temperature.  Colonic  flushing  with  cool  water  may 
be  useful.  If  the  temperature  is  subnormal,  the  hot  water  bottle, 
stupes,  and  fomentations  are  indicated. 

Treat  the  various  symptoms  as  they  arise.  For  the  abdominal 
pain,  deep,  steady  pressure  in  the  lower  thoracic  spinal  area  is 
indicated.  Hot  fomentations  may  help  when  applied  to  the  stom- 
ach and  abdomen.  The  early  denial  of  all  food  is  best.  Barley 
water  may  be  given  in  small  quantity  every  hour  to  relieve  the 
thirst.    Very  warm  water  sometimes  relieves  the  vomiting. 

The  lactic-acid  diet  depends  upon  the  bacteriology  of  the  dis- 
ease as  given  above.  Skimmed  milk  is  acted  upon  by  any  of  the 
lactic-acid  bacilli  in  a  warm  room  for  twenty-four  hours ;  the  "but- 
termilk" thus  formed  is  fed  to  the  child  according  to  age,  at  inter- 
vals of  two  to  four  hours.  Three  to  eight  ounces  are  given  at 
each  feeding.  This  method  gives  very  good  results,  in  the  expe- 
rience of  certain  physicians.  In  any  case,  return  to  the  ordinary 
diet  must  be  cautiously  made. 

Change  of  air  is  one  of  the  usual  recommendations. 

The  child  must  be  guarded  from  nervous  excitement  for  sev- 
eral weeks  after  an  attack. 

J  Prognosis.  The  condition  is  grave  in  all  cases.  Death  or  con- 
valescence or  a  change  to  a  less  acute  form  usually  occurs  in  from 
one  to  four  days.    Recurrence  has  a  graver  prognosis. 


84  ENTERITIS  OF  CHILDREN 

ACUTE  INFECTIOUS  ENTERITIS  OF  CHILDREN 

(Catarrhal  ileo-eolitis;  ulcerative  enteritis  or  entero-colitis ;  follicular  enteritis; 
inflammatory  diarrhea) 

Infectious  enteritis  affects  the  lower  portion  of  the  ileum  and 
involves  the  colon  also;  it  occurs  usually  in  children  under  two 
years  of  age,  and  is  characterized  by  vomiting,  persistent  and 
irregular  fever,  and  marked  prostration.  Blood  and  quantities  of 
mucus  appear  early  in  the  stools. 

Etiology.  The  predisposing  causes  are  hot  weather,  debility  due 
to  teething,  and  improper  feeding.  The  usual  bony  lesions  include 
chiefly  the  lumbar  spine,  especially  a  rigidity  of  this  area.  The 
spinal  condition  is  certainly  an  important  predisposing  factor. 

The  exciting  causes  are  the  pyogenic  cocci  or  the  bacillus  dyscn- 
teriae  of  the  Shiga  or  Flexner  type. 

The  pathological  changes  are  found  in  the  epithelium  of  the 
mucosa  of  the  ileum  and  colon,  the  infiltration  of  which  may  be 
so  great  as  to  affect  the  submucosa  with  the  production  of  necrosis 
and  the  formation  of  ulcers. 

Diagnosis.  In  mild  cases  there  is  a  diarrhea  of  greenish,  offen- 
sive stools  which  may  contain  undigested  casein  in  curds  like 
"chopped  spinach,"  numbering  from  fifteen  to  thirty  in  twenty- 
four  hours;  abdominal  pain  causing  great  restlessness  and  irrita- 
bility ;  fever  of  slight  degree ;  and  vomiting.  The  tongue  is  furred 
and  moist  at  first,  later  becoming  red  and  dr3^ 

In  cases  of  moderate  severity  the  onset  is  sudden,  often  with 
vomiting,  abdominal  pain,  and  fever,  102°  to  104°  F.  at  first;  later, 
99°  to  102°  F. ;  and  frequent,  thin,  green  or  yellow  stools  which  are 
partly  fecal  and  partly  undigested  food.  Later,  the  discharges  con- 
tain mucus  and  blood,  rarely  in  clots  and  usually  streaking  the 
mucus.  The  stools  are  almost  odorless.  The  appetite  is  lost  and 
the  tongue  is  coated.  Prolapsus  ani  is  frequent.  There  is  con- 
siderable prostration  and  marked  loss  of  weight.  The  convales- 
cence is  slow  and  begins  about  a  week  after  the  onset  of  the 
disease. 

In  severer  cases  the  symptoms  suggest  bacterial  intoxication. 
Vomiting  and  diarrhea  are  urgent;  the  abdomen  distended  or  hol- 
low, and  very  tender;  the  temperature  104°  to  105°  F. ;  wasting 
is  rapid,  and  collapse  and  coma  may  cause  death  in  a  few  days. 

Treatment.  "Relaxation  of  the  contracted  muscles  by  strong 
deep  pressure  brings  to  our  assistance  the  normal  inhibitory  func- 
tion of  the  splanchnics.  Gentle  springing  of  the  spine  also  seems 
to  help  in  freeing  the  contraction.  A  general  spinal  treatment  is 
indicated  in  these  bowel  conditions,  as  the  whole  vasomotor  system 
is  deranged  as  evidenced  by  the  cold  face,  chest,  abdomen  and 
extremities,  hot  back  and  congested  mesenteric  vessels.    Of  course. 


INFECTIOUS  ENTERITIS  85 

the  spinal  bony  tesion  must  be  corrected,  but  just  when  in  the 
course  of  the  disease  it  is  wise  to  attempt  this,  I  believe  depends 
on  the  vitality  of  the  child  and  the  severity  of  the  condition.  *  *  * 

"Sometimes  I  place  the  child  on  its  chest  on  my  lap  or  on  its 
bed  and  extend  the  legs,  gently  pressing  on  spine,  maving  pressure 
on  spine,  moving  pressure  with  each  elevation  of  the  legs  with 
some  lateral  bending  of  the  spine  at  the  same  time.  *  *  *  The  Old 
Doctor  says  take  the  child  in  your  lap  and  have  him  throw  his 
arms  over  your  shoulder,  then  begin  at  the  fifth  lumbar  and  adjust 
from  the  fifth  lumbar  to  the  occiput,  remembering  that  it  is  a  child 
you  are  handling  and  knowing  well  that  it  requires  but  little  force 
to  adjust  and  loosen  up  the  entire  spine." — Nettie  M.  Hurd. 

Raising  the  lower  ribs,  holding  them  for  the  time  of  one  breath, 
is  helpful.  With  the  child  held  by  the  right  arm  around  the  upper 
part  of  the  body,  the  left  hand  may  raise  the  child's  right  ribs; 
then,  with  the  left  arm  holding  the  child's  body,  the  right  hand 
may  raise  the  left  ribs.  Spinal  treatment  may  be  given  with  the 
child  in  the  same  position.  It  is  sometimes  possible  to  give  such 
treatments  standing,  when  the  child  would  cry  and  struggle  if  the 
attempt  is  made  to  hold  him  upon  the  lap.  Every  effort  must  be 
made  to  prevent  struggling;  the  nervous  effects  may  be  pro- 
foundly depressing.  In  a  few  cases,  if  the  pathology  permits,  deep 
but  very  careful  work  over  the  abdomen  is  effective. 

Diet.  All  milk  foods,  of  whatever  kind,  must  be  stopped  at 
once.  Barley  water,  rice  water,  may  be  given  in  the  amounts 
and  at  the  times  of  the  usual  feeding.  A  small  amount  of  chicken 
or  other  broth  may  be  added  to  make  these  palatable,  if  necessary. 
Sugar  is  permissible  also;  indeed,  sugar  is  often  advised  in  order  to 
give  the  necessary  fuel  for  the  needs  of  the  body,  thus  preventing 
too  great  loss  of  weight  from  the  high  fever.  As  convalescence 
progresses,  the  return  to  ordinary  diet  must  be  cautiously  made, 
watching  the  effect  of  each  change  and  keeping  the  bodily  struc- 
ture of  the  child  always  under  close  supervision. 

Let  the  child  wear  a  single,  loose  garment.  Napkins  or  pads 
of  soft  cloth  should  be  placed  under  the  buttocks,  and  these 
removed  as  often  as  soiled ;  sores  are  apt  to  occur  if  cleanliness 
is  not  constant.  The  soiled  cloths  should  be  burned  or  else  imme- 
diately drbpped  into  some  antiseptic  solution,  to  be  boiled  later, 
before  being  used  again.  Since  the  fecal  material  contains  the 
infectious  agents,  the  utmost  care  must  be  used  to  prevent  reinfec- 
tion of  the  child,  or  the  infection  of  others. 

A  flannel  band  or  pad  over  the  abdomen  is  often  advised. 
Warmth  is  usually  required ;  a  small  hot  water  bottle  over  the 
abdomen  may  relieve  the  pain.  Hot  stupes  may  give  more  speedy 
relief,  carefully  avoiding  chill  in  changing. 


86  ENTERITIS  OF  CHILDREN 

For  several  months  after  such  an  attack  the  fats  must  be  kept 
down  to  a  minimum.  Olive  oil  may  sometimes  be  used  when  milk 
fats  are  not  well  handled. 

Colon  irrigation  is  useful.  When  there  is  profuse  diarrhea  this 
washes  out  the  irritating  material,  cleans  the  membrane,  and  per- 
mits more  rapid  recovery.  The  normal  salt  solution  should  be 
quite  warm — 105°  to  110°  F. — and  should  be  thoroughly  given  at 
least  once.  If  no  good  effects  are  noted,  or  if  the  child  struggles 
and  cries  when  the  procedure  is  properly  carried  out,  it  need  not 
be  repeated.  Usually  this  warm  irrigation  diminishes  the  pain  and 
the  peristalsis,  and  gives  opportunity  for  several  hours'  rest.  Too 
frequent  use  of  the  enema  or  irrigation  is  to  be  avoided — twice  a 
day  is  the  most  that  is  allowable,  except  in  exceptional  cases. 
There  is  no  reason  for  attempting  to  insert  the  tube  a  long  distance 
— the  reversed  peristalsis  carries  the  fluid  well  around  to  the  cecal 
region,  and  sometimes  into  the  small  intestines,  through  the  relaxed 
ileo-cecal  valve. 

When  the  irritation  of  the  colon  is  profound,  as  when  much 
blood  and  mucus,  and  violent  straining,  are  noted,  thin  boiled 
starch  solutions  may  be  injected.  Thin  flaxseed  solution,  is  also 
used.  These  act  as  a  mechanical  protection  to  the  wall  t)f  the 
colon,  and  are  very  soothing  in  most  cases.  The  old-fashioned 
starch-and-laudanum  mixture  is  dangerous,  on  account  of  the  pos- 
sibility of  the  absorption  of  the  laudanum. 

Gastric  lavage  may  be  necessary  if  the  vomiting  is  severe, 
especially  during  the  first  few  days.  It  should  not  be  used  unless 
there  is  reason  to  believe  that  irritating  substances  are  still  present 
in  the  stomach.  The  washing  that  is  secured  by  the  vomiting  of 
considerable  amounts  of  water,  or  of  the  food  substitutes  already 
mentioned  is  usually  sufficient. 

After  the  temperature  returns  to  the  normal,  the  diarrhea 
ceases,  and  the  feces  appear  normal,  a  more  rapid  convalescence 
is  secured  by  a  change  of  climate.  Perhaps  this  is  partly  due  to 
the  lessened  risk  of  reinfection,  but  it  is  also  partly  due  to  the  tonic 
influence  of  the  change.  Especially  a  change  from  sea  or  lakeside 
to  mountains,  or  from  inland  towns  to  the  sea,  greatly  facilitate 
recovery. 

Prognosis.  The  usual  duration  of  the  disease  is  ten  to  fifteen 
days.  Vigorous  children  in  good  surroundings  nearly  always 
recover  promptly ;  weak  children,  those  who  are  teething  and  those 
placed  in  unhygienic  surroundings,  give  rather  a  gloomy  prospect. 
Good  nursing  with  the  treatment  as  indicated  should  lead  to  recov- 
ery in  all  uncomplicated  cases. 

Sequelae.  After  an  attack,  the  lumbar  spinal  column  is  left 
more  rigid  than  normal;  no  doubt  this  is  partly 'the  reason  why 


CHRONIC,  BNTERO-COUTIS  87 

e^h  attack  lessens  the  resistance  to  later  attacks  of  this  as  well  as 
of  other  forms  of  enteritis. 


CHRONIC  ENTERO-COLITIS  OF  CHILDREN 

(Chronic  enteritis;  chronic  intestinal  indigestion;  chronic  ileo-colitis) 

Chronic  entero-colitis  is  a  disease  involving  the  lower  ileum 
and  the  colon,  associated  with  varying  inflammatory  derangement 
of  the  other  parts  of  the  digestive  tract,  and  characterized  by  mal- 
nutrition, nervous  instability  and  alternating  constipation  and 
diarrhea. 

Etiology.  It  follows  repeated  attacks  of  acute  enteritis,  and 
is  chiefly  due  to  bad  food,  imperfect  hygiene,  and  changeable,  espe- 
cially hot  and  humid,  climates.  Bony  lesions  of  the  dorso-lumbar 
region  are  important  factors. 

The  children  are  always  thin,  pale,  sallow,  anemic,  with  dark 
rings  around  the  eyes  and  mouth.  The  abdomen  is  large  and  pro- 
tuberant— this  is  partly  due  to  the  anterior  lumbar  spine  so  often 
present.  Flatulence  is  usual.  The  bowels  are  usually  constipated, 
with  pale  stools,  lumpy,  very  foul  in  odor.  Attacks  of  diarrhea 
occur,  with  large,  thin,  gray  or  brown  stools,  frothy,  foul,  and 
frequently  containing  fragments  of  undigested  food.  Considerable 
quantities  of  mucus  and  sometimes  a  little  blood  may  be  passed. 

The  appetite  is  whimsical ;  the  tongue  may  or  may  not  be 
coated ;  the  breath  may  or  may  not  be  foul. 

The  nervous  symptoms  vary  from  a  general  irritability  to 
seizures  resembling  petit  mal.  Convulsions  may  be  epileptoid. 
The  child  is  easily  fatigued,  cross,  irritable,  and  emotional  to  an 
unnatural  degree.  Sleep  is  disturbed,  night  terrors  are  frequent; 
grinding  of  the  teeth  during  sleep  is  characteristic.  Convulsions 
may  occur  during  the  diarrheal  attacks. 

There  may  be  fever,  99°  to  105.5°  F.,  from  toxic  causes. 

The  lumbar  spine  is  rigid  and  usually  anterior ;  posterior  lesions 
of  the  dorso-lumbar  region  are  sometimes  present.  Anterior  lower 
thoracic  is  often  associated  with  the  posterior  lumbar  condition. 
Lesions  involving  the  cervical  region  have  been  reported.  Coccyx 
lesions  may  also  be  found. 

Cervical  lesions  are  more  common  in  children  in  whom  the 
nervous  symptoms  are  most  pronounced. 

Diagnosis.  This  condition  may  be  distinguished  from  true 
epilepsy  by  the  character  of  the  attacks,  which  are  rarely  typically 
epileptical ;  from  kidney  disease,  by  urinalysis ;  from  intestinal 
parasites  by  the  character  of  the  stools ;  and  from  the  ordinary 
diseases  of  mal-nutrition,  by  the  lack  of  skeletal  changes  and  the 
history  of  the  case.    It  is  often  associated  with  rickets,  marasmus, 


88  ENTERITIS  OF  CHILDREN 

epilepsy  and  kidney  disease,  in  which  cases  diagnosis  presents 
difficulties. 

Treatment.  This  is  hygienic,  dietetic  and  corrective.  The  cor- 
rection of  the  bony  lesions  as  found,  with  increased  mobility  of 
the  ribs  and  the  lumbar  spine,  usually  gives  better  appetite,  better 
sleep  and  better  digestion.  The  clothing  must  be  light  and  loose, 
and  not  too  warm ;  chilling  of  the  body  must  be  prevented.  Much 
open  air  is  necessary;  a  change  of  climate  is  advisable  if  this  is 
possible. 

Daily  massage  once  a  day  is  helpful;  the  mother  should  be 
taught  to  do  this.  If  some  oily  substance  is  provided,  with  instruc- 
tions to  "rub  in"  a  given  quantity,  the  massage  is  more  comfort- 
able and  a  definite  end  is  provided.  A  cool  bath  daily,  with  warm 
baths  for  cleanliness  and  when  the  nervous  symptoms  are  more 
pronounced  is  advisable.  All  baths  should  be  followed  by  a  good 
rub-down. 

Diet.  For  young  infants,  good  breast  milk  is  most  important. 
If  this  is  impossible,  artificial  foods  must  be  tried,  one  after  another, 
until  a  suitable  food  is  found.  Starches  are  to  be  absolutely  for- 
bidden ;  thoroughly  dextrinized  foods  in  which  practically  no  starch 
is  present  may  sometimes  be  allowed. 

White  of  egg  beaten  in  water  and  strained;  peptonized  milk; 
toast  water;  beef  juice;  scraped  beef  or  mutton,  lightly  broiled; 
buttermilk  and  junket  may  be  given  to  suitable  ages  of  children. 
The  juice  of  fresh  fruit,  especially  oranges,  should  be  given  one 
hour  before  the  meal,  once  a  day. 

After  two  months  of  improvement,  stale  bread,  cut  thin  and 
dried  until  crisp,  may  be  given  in  small  quantity  and  with  no  butter. 
Broths  of  mutton,  beef,  or  chicken  may  replace  a  milk  feeding 
occasionally.     A  little  vegetable  juice  should  be  added. 

After  three  or  four  months  of  improvement,  green  vegetables, 
preferably  spinach,  stewed  celery,  etc.,  may  be  added  once  a  day. 

After  two  or  three  months  more  of  gain,  thoroughly  cooked 
rice  or  macaroni  may  be  given  twice  weekly.  With  this  diet,  the 
child  can  get  along  comfortably  for  a  year  or  so  and  no  larger 
variety  given  until  all  symptoms  have  disappeared  for  some  time. 

Free  water  drinking  is  to  be  encouraged. 

The  nursing  is  a  very  important  factor.  Enemas  are  to  be 
given  according  to  the  bowel  conditions,  varying  with  the  needs 
of  the  patient.  Too  much  irrigation  of  the  colon  is  irritating,  yet 
the  presence  of  irritant  feces  must  not  be  permitted.  Hospital 
nursing  gives  better  results  than  home  care,  unless  the  latter  is 
unusually  good. 

Prognosis.  Recovery  is  always  very  slow,  though  marked 
improvement  usually  follows  the  first  two  or  three  treatments  and 
change  in  diet.     The  prognosis  is  better  where  the  diet  and  the 


CHRONIC  ENTERO-COUTIS  89 

hygiene  have  been  very  bad,  and  when  pronounced  bony  lesions 
can  be  found,  unless  the  child  has  lost  too  much  strength  before 
treatment  is  begun. 

Sequelae.  When  the  patient  can  be  kept  under  observation  until 
recovery  is  complete  no  sequelae  are  to  be  expected.  When  abnor- 
mal conditions  of  the  cervical  or  lumbar  vertebrae  are  allowed  to 
remain,  recurrence  of  the  enteritis  and  a  tendency  to  gastro-intes- 
tinal  disease  may  remain  throughout  life.  A  tendency  to  nervous 
disorders  probably  results  partly  from  the  absorption  of  the  poi- 
sons and  partly  from  persistent  cervical  lesions. 

Prophylaxis.  Better  education  of  mothers  along  hygienic  lines ; 
more  frequent  examination  of  children's  physical  condition ;  better 
hygiene  and  sanitation  everywhere,  must  ultimately  eliminate  the 
disease. 

CCELIAC  AFFECTION 

(Diarrhea  alba;  diarrhea  chylosa) 

The  coeliac  affection  is  a  peculiar  disease  of  children  marked  by  pale,  loose, 
offensive  stools,  progressive  emaciation  and  ultimately  proving  fatal. 

Pathology.  Ulcers  have  been  found  in  the  intestine.  Little  is  knovirn 
of  the  intestinal  state. 

Etiology.  It  affects  children  from  one  to  five  years  and  Is  not  associated 
with  either  tuberculosis  or  other  hereditary  disease.  Filaria  sanguinis  hominis 
has  been  found  in  the  feces  in  a  few  cases. 

Diagnosis.  The  symptoms  begin  insidiously  with  progressive  wasting  and 
pallor,  the  belly  becomes  doughy  and  inelastic,  there  is  often  flatulence,  fever  is 
not  often  present,  and  the  disease  is  lingering.  The  stools  are  pale,  loose,  gruel- 
like, bulky,  not  watery,  frothy,  and  extremely  offensive. 

Examination  of  the  stools,  urine,  and  blood  for  evidences  of  filaria  should 
be  made. 

Treatment.  No  cases  have  been  reported  by  osteopathic  physicians.  Symp- 
tomatic treatment  according  to  conditions  as  found  is  indicated.  Careful  study 
should  be  made  in  each  case,  and  the  treatment  determined  from  the  results  of 
this  study. 

Prognosis.    Fatal,  usually  in  a  few  days,  according  to  medical  reports. 


CHAPTER  VIII 
INTESTINAL  INFLAMMATIONS  OF  ADULTS 

ACUTE  ENTERITIS 

(Intestinal  catarrh;   muco-enteritis ;   inflammation  of  the  bowels;   duodenitis; 

jejunitis;  ileitis;  colitis;  catarrhal  enteritis;  acute  diarrhea; 

acute  entero-colitis  of  adults) 

This  is  a  catarrhal  inflammation  involving  the  mucous  mem- 
brane of  all  or  any  part  of  the  intestine,  characterized  by  diarrhea 
and  abdominal  pain,  without  tenesmus. 

The  localizing  terms,  duodenitis,  jejunitis,  and  ileitis,  etc.,  have  little  prac- 
tical value  for  they  are  of  difficult  diagnosis.  Duodenitis  is  usually  associated 
with  gastritis;  when  abdominal  pjiin  and  tenderness  on  palpation,  gastritis,  and 
constipation  occur,  duodenitis  may  be  suspected;  when  the  swelling  of  the  mem- 
brane closes  the  bile  duct,  and  jaundice  is  present,  the  diagnosis  of  duodenitis 
is  fairly  certain.  In  ileitis  the  colon  is  usually  affected  also,  and  the  symptoms 
of  colitis  appear.  Undigested  food  remnants,  the  absence  of  symptoms 
of  colitis,  formed  stools  containing  flecks  of  mucus,  point  to  jejunitis.  Un- 
changed bile,  flecks  of  mucus  often  bile-stained  and  intermingled  with  the  rather 
solid  feces,  point  to  a  wide  inflammation  of  the  small  intestine. 

Reflex  muscular  contractions  along  the  spinal  column  help  in  localizing 
the  disease — from  duodenitis  with  its  reflexes  as  high  as  the  fifth  or  sixth 
thoracic  spines,  to  colitis,  with  its  reflex  muscular  contractions  involving  chiefly 
the  lumbar  region,  and  proctitis,  involving  the  lumbar  and  sacral  segments, 
there  is  a  fairly  constant  representation  of  the  segmental  innervation  of  the 
intestinal  tract  in  the  spinal  musculature. 

Etiology.  The  causes  may  be  structural  or  environmental. 
The  structural  causes  include  weakened  resistance,  and  the  pres- 
ence of  bony  lesions,  especially  of  the  dorso-lumbar  spinal  column. 
Lesions  as  high  as  the  fifth  thoracic  vertebra  affect  the  upper  part 
of  the  tract,  and  lesions  of  the  lumbar  vertebrae,  innominates  and 
sacrum  affect  the  colon  and  rectum.  These  lesions  predispose  to 
disease  of  the  intestinal  tract,  and  there  may  be  further  localizing 
factors  in  the  character  of  the  exciting  causes.  Sudden  strains 
affecting  these  spinal  areas  may  be  the  exciting  cause  of  an  acute 
enteritis  which  is  very  closely  localized  according  to  the  segmental 
innervation  of  the  intestinal  walls. 

The  environmental  causes  include  sudden  changes  in  tempera- 
ture; dietetic  errors,  such  as  improper  foods,  spoiled  foods,  very 
cold  drinks,  hasty ,  eating,  especially  when  tired  or  emotionally 
excited ;  bacterial  toxins ;  drugs,  such  as  mercury,  arsenic,  morphine 
in  some  individuals,  purgatives,  alcohol. 

Diagnosis.  The  chief  symptoms  are :  griping,  and  colicky  pains, 
followexi  by  diarrhea  (four  to  twenty  or  more  stools  in  twenty-four 
hours) ;   borborygmi ;   nausea,   anorexia,   slight  or   no   fever,   and 

90 


ACUTE  ENTERITIS  91 

weakness  depending  upon  the  diarrhea.  Thirst  is  often  severe. 
Oliguria  depends  upon  the  diarrhea. 

The  feces  show  undigested  food ;  epithelial  debris ;  mucus 
flecks  which  are  bile-stained  and  intermingled  with  the  fecal 
masses ;  bile  pigments ;  triple  phosphates,  and  various  micro-organ- 
isms. When  the  colon  is  not  involved,  the  fecal  masses  may  be 
formed  and  solid.  With  the  occurrence  of  colitis  the  feces  are  thin 
and  very  offensive,  sometimes  containing  blood  and  large  masses 
of  mucus,  approaching  the  dysenteric  character. 

Reflex  muscular  contractions  are  constant;  the  spinal  and 
abdominal  muscles  affected  give  information  as  to  the  locality  of 
the  greatest  irritation. 

There  is  some  tympanites,  not  often  pronounced.  The  tongue 
is  furred  and  dry.  Splenic  enlargement  may  be  found,  which  sub- 
sides with  recovery.  When  there  is  marked  prostration,  headache, 
high  temperature,  pain  in  the  joints,  a  specific  infection  should  be 
suspected. 

Sometimes  what  seems  to  be  a  simple  acute  enteritis  leads  rapidly  to 
symptoms  of  overwhelming  toxemia,  collapse  and  death.  This  is  due  either  to 
malignant  disease,  before  unsuspected;  perforation;  complications,  such  as 
cardiac  disease,  arterio-sclerosis,  nephritic,  or  diabetes;  or  to  the  presence  of 
specific  micro-organisms. 

Treatment.  Rest  in  bed  is  absolutely  necessary.  Spinal  relax- 
ation of  the  contracted  muscles,  correction  of  the  lesions  present 
in  the  individual  case,  and  regulation  of  the  circulation  is  indi- 
cated. The  diarrhea  usually  stops  spontaneously  when  the  irritant 
has  been  expelled.  But  if  it  continues  after  a  reasonable  time 
has  elapsed  warm  enemas  should  be  given  to  wash  away  the  rem- 
nants of  irritating  materials.  Deep  steady  pressure  at  the  second 
lumbar  vertebra  may  check  the  peristalsis  and  give  rest. 

Hot  fomentations  to  the  abdomen  are  useful.  Very  careful 
work  over  the  abdomen  may  be  beneficial.  The  diet  must  be 
absolutely  restricted  to  hot  water  or  thin  malted  milk  until  the 
symptoms  show  decided  improvement. 

In  sigmoiditis  and  proctitis  the  tenesmus  and  colicky  pains  can 
usually  be  controlled  by  relaxing,  inhibiting  and  stretching  the 
sacral  and  lumbar  spinal  tissues. 

Prognosis.  The  outlook  is  usually  good.  The  duration  is  from 
three  to  ten  days,  according  to  the  severity  of  the  case.  The  dis- 
ease may  pass  into  the  chronic  form  if  the  etiological  factors  are 
not  removed. 

Prophylaxis.  Public  hygiene  Requires  the  utmost  carefulness  in 
regard  to  the  cleanliness  of  the  water  and  milk  supply.  Individual 
prophylaxis  consists  in  carefulness  of  the  diet  in  the  summer  and 
autumn,  that  the  food  is  unspoiled  in  any  manner,  that  dairy  prod- 
ucts are  clean  and  sweet,  and  that  fruit  is  ripe  and  not  decayed. 


92  INTESTINAL  INFLAMMATIONS 

Maintenance  of  correct  spinal  relations  is  important  in  prophy- 
laxis. 

CROUPOUS  ENTERITIS 

(Membranous  enteritis) 

Croupous  enteritis  is  an  inflammation  of  the  intestinal  mem- 
brane, characterized  by  tenderness,  paroxysmal  pains,  moderate 
fever,  and  the  discharge  of  membranous  shreds  or  casts  in  the 
stools. 

Etiology.  The  condition  may  be  terminal,  in  the  final  stages  of 
chronic  constitutional  diseases,  or  it  may  occur  secondarily,  in  the 
acute  infectious  diseases.  Certain  poisons,  as  mercury,  lead  and 
arsenic;  or 'the  mechanical  irritation  of  impacted  feces,  gall-stones, 
or  intestinal  "sand"  may  cause  the  condition. 

Diagnosis.  The  condition  may  not  be  recognized  ante  mortem, 
or  it  may  present  fairly  typical  symptoms.  Paroxyms  are  usually 
preceded  by  various  neurotic  symptoms.  There  are  feverishness, 
soreness,  tenderness,  and  distention  of  the  abdomen,  spasmodic 
colicky  pains  around  the  umbilicus;  these  symptoms  continue  for 
a  day  or  two  and  are  then  followed  by  diarrhea,  pain,  tenesmus, 
with  the  appearance  of  mucus,  shreds  of  membrane,  or  cylindrical 
casts  of  the  bowel,  and  sometimes  blood. 

Treatment.  Palliative  treatment  includes  that  indicated  in  acute 
catarrhal  enteritis,  until  the  underlying  causes  can  be  found,  and, 
if  possible,  removed.  The  diet  must  be  urgently  restricted;  the 
liquids  taken  should  be  diminished  until  the  symptoms  disappear. 
The  condition  is  always  serious,  and  the  patient  must  receive  care- 
ful nursing. 

Prognosis.  In  the  acute  infections,  not  otherwise  serious,  recov- 
ery is  to  be  expected.  In  cases  with  history  of  long  constitutional 
disease,  the  prognosis  is  very  grave;  not  rarely  croupous  enteritis 
initiates  the  terminal  stages  of  such  diseases. 


ULCERATIVE  ENTERITIS 

The  intestine  is  subject  to  many  forms  of  ulceration,  the  following  of  which 
may  be  mentioned :  enteric  and  dysenteric  forms',  duodenal  ulcer,  catarrhal  and 
follicular  ulcers.  These  have  already  been  described  under  their  respective  heads. 
Specific  ulcers  may  occur  in  syphilis  and  in  tuberculosis. 

Syphilitic  ulcers  occur  most  frequently  in  the  rectum  and  mostly  in  women. 
They  are  due  to  the  growth  of  gummata  in  the  submucosa  and  the  gradual 
onset  of  a  hard  fibrous  stricture,  easily  distinguished  from  cancer. 

Tuberculosis  affects  principally  the  ileum,  cecum,  and  colon.  The  ulcers 
are  irregular,  their  long  diameter  in  the  circumference  of  the  bowel,  their 
edges  infiltrated  and  undermined,  involving  the  submucosa  and  Jhe  muscular 
coats.    They  may  perforate  the  bowel.    Cicatrization  may  cause  stricture. 


CHOLBRA  MORBUS  93 

Symptoms.  The  main  symptoms  are  periodic  pain,  alternating  constipa- 
tion ?ind  diarrhea,  and  slowly  advancing  stricture.  An  elongated,  hard,  and 
tender  tumor-like  mass  may  be  found  in  the  right  iliac  fossa.  It  is  localized 
and  removable  by  operation. 

Treatment.    The  systemic  treatment  is  most  important. 

PHLEGMONOUS  ENTERITIS.  (Abscess  of  the  bowels.)  This  is 
due  to  pyogenic  infection  of  the  intestinal  membrane  after  it  has  been  injured 
by  strangulated  hernia,  total  obstruction  of  any  kind,  interference  with  the 
circulation,  or  by  trauma.  It  is  rarely  found  below  the  duodenum.  Diagnosis 
is  difficult;  often  impossible  ante  mortem. 

When  the  diagnosis  can  be  made,  the  early  evacuation  of  the  pus  is  impor- 
tant. Deep,  steady  pressure  over  the  spinal  areas  of  reflex  muscular  contrac- 
tion, application  of  heat  or  cold  to  the  abdormen  may  relieve  the  pain.  Sometimes 
the  pus  evacuates  into  the  intestine,  and  recovery  occurs  spontaneously.  There 
is  great  danger  of  rupture  into  the  peritoneum,  when  death  is  usually  inevitable. 


CHOLERA  MORBUS 

(Cholera  nostras;   sporadic  cholera;   English^  cholera) 

Cholera  morbus  is  an  acute  inflammation  of  the  mucosa  of  the 
stomach  and  intestines,  of  sudden  onset,  and  marked  by  violent 
abdominal  pain,  incessant  vomiting  and  purging,  cold  surfaces, 
rapid,  feeble  pulse,  and  spasmodic  contractions  of  the  abdominal 
and  leg  muscles  with  prostration. 

Etiology.  It  is  more  common  in  children,  but  is  not  rare  in 
adults.  The  exciting  cause  is  probably  microbic.  The  specific 
organism  has  not  been  isolated.  The  predisposing  causes  are 
unripe  and  decomposing  fruit  and  vegetables,  and  hot  weather  with 
high  humidity  and  sudden  changes. 

Diagnosis.  There  is  sudden  onset  with  vomiting  and  purging, 
very  severe  and  paroxysmal  pain  in  the  upper  abdomen,  the  sur- 
face is  cold  and  covered  with  a  clammy  sweat,  severe  muscular 
cramps,  and  pulse  small  and  feeble.  There  is  intense  thirst.  Col- 
lapse may  occur.  The  vomitus  at  first  consists  of  the  stomach 
contents,  then  bile,  and  later,  water  and  greenish-colored  fluid  bitter 
to  the  taste.  The  stools  are  frequent  and  often  continuous  and 
resemble  the  Asiatic  cholera  "rice-water  stools"  in  character. 

Treatment.  If  the  violent  vomiting  and  purging  have  not 
already  cleared  out  the  offending  material,  the  stomach  should 
be  washed  and  enemas  given. 

Deep,  steady  pressure  applied  from  the  ninth  to  twelfth  tho- 
racic vertebrae  helps  quiet  the  sensory  nerves  from  this  area. 
Often  pressure  over  the  solar  plexus  through  the  abdominal  wall 
will  produce  the  same  result.  If  there  is  any  sign  of  collapse,  apply 
heat  to  the  abdomen  after  giving  the  above  treatment. 

Correction  of  any  bony  or  muscular  lesions  found  protects  the 
patient  against  further  attacks. 


94  INTESTINAL  INFLAMMATIONS 

If  the  cramps  are  in  the  legs,  deep,  steady  pressure  over  the 
sacrum  will  usually  relieve  them.  Carefully  elevate  the  viscera. 
No  food  should  be  given  until  the  acute  symptoms  have  disap- 
peared. After  the  pain  has  subsided,  especially  if  the  blood  pres- 
sure is  low,  corrective  treatment  given  briskly  permits  the  most 
speedy  return  to  normal  tonicity  of  the  affected  viscera.  Increased 
mobility  of  the  lower  thoracic  spinal  region,  and  raising  of  the 
lower  ribs  is  usually  indicated. 

Prognosis.  Recovery  is  usual  although  death  may  occur  within 
two  days  of  onset.  The  mild  cases  recover  spontaneously  in  a 
few  days.  The  severer  cases  persist  for  a  week  or  more  and 
under  medical  treatment  are  followed  by  a  tedious  convalescence. 
With  osteopathic  treatment  the  course  of  the  disease  is  usually 
shortened,  convalescence  is  less  tedious,  recovery  is  complete,  and 
the  frequent  sequelae  due  to  the  use  of  severe  drugs,  as  well  as  to 
the  disease  itself,  are  not  encountered. 


ACUTE  COLITIS 

(Acute  dysentery;  ulcerative  colitis;  bloody  flux) 
This  is  an  acute  inflammation  of  the  mucous  membranes  of  the 
large  intestine  caused  by   irritating  foods,  bad   hygiene,  impure 
water,  and  the  cachectic  state,  and  characterized  by  fever,  tormina, 
tenesmus,  and  frequent  mucous  and  bloody  stools. 

Diagnosis.  The  disease  begins  gradually  with  diarrhea,  ano- 
rexia, nausea,  and  very  slight  fever.  These  symptoms  may  continue 
for  three  or  four  days  when  there  is  pain  on  pressure  along  the 
course  of  the  transverse  and  descending  colon,  colicky  pains 
about  the  umbilicus,  burning  pain  in  the  rectum  with  tenesmus 
especially  when  the  bowels  move  and  for  a  short  time  afterward. 

The  stools  vary  from  five  to  twenty  in  twenty-four  hours.  For 
the  first  day.  or  two  the  stools  contain  more  or  less  fecal  matter, 
soon  changing  to  a  grayish,  tough,  transparent  mucus  containing 
more  or  less  blood  and  pus.  During  the  tormina,  pain  and  vomit- 
ing may  occur.    The  urine  is  scanty  and  high-colored. 

Treatment.  As  considerable  muscular  contraction  is  found  in 
the  lower  dorsal  and  lumbar  even  to  the  coccygeal  regions,  the 
relaxation  of  these  ar,eas  is  indicated  with  the  correction  of  any 
deviations  found.  Interosseous  rotations  are  commonly  found  be- 
tween the  second  and  the  fourth  lumbars,  which,  if  adjusted,  will 
usually  give  quick  relief.  Careful,  deep  treatment  of  the  abdomen  is 
sometimes  effective.  As  soon  as  possible  the  irritating  material 
should  be  removed  from  the  bowel,  by  enemas  and  by  careful,  gen- 
tle raising  of  the  colon.  Food  should  be  withheld  until  convales- 
cence begins  when  the  most  easily  digested  with  the  least  residue 


APPENDICITIS  95 

can  be  given.    If  the  patient  becomes  much  weakened,  malted  milk, 
broths  or  albumen  water  may  be  given. 

Prognosis.  Recovery  is  to  be  expected  in  about  a  week,  in 
patients  not  already  weakened  by  other  causes.  Convalescence  may 
be  tedious  and  wasting  rather  marked.  Aged  patients,  and  those 
weakened  from  any  cause,  may  die  in  the  second  or  third  week,  or 
may  linger  for  a  longer  time,  with  either  recovery  or  death.  Per- 
foration and  hemorrhage  rarely  occur.  Recurrences  are  to  be 
expected,  if  dietetic  errors  are  permitted. 


APPENDICITIS 

(Perityphlitic  abscess;  suppurative  appendicitis;  typhlitis;   skolikoiditis ;  scole- 
citis;  pericecal  abscess;  iliac  abscess;  paratyphlitis) 

The  symptoms  of  typhlitis  are  identical  with  those  of  appendicitis,  hence 
the  term  is  here  included,  although  this  inflammation  may  occur  as  a  separate 
disease. 

Appendicitis  is  inflammation  of  the  vermiform  appendix  of  the 
cecum ;  characterized  by  pain  in  the  right  iliac  fossa,  tenderness  at 
McBurney's  point,  rigidity  of  the  right  rectus  muscle,  and  general 
symptoms  of  nausea,  vomiting,  constipation,  and  fever. 

Etiology.  Appendicitis  is  due  to  infection  by  the  bacillus  coli, 
pyogenic  cocci,  or  bacillus  proteus  upon  an  abraded  surface  caused 
by  some  irritant  from  the  food,  or  fecal  concretions,  or  due  to 
perverted  blood  and  nerve  supply  resulting  from  subluxated  lower 
ribs  or  the  vertebrae  from  the  tenth  thoracic  to  the  third  lumbar. 
A  number  of  cases  will  respond  immediately  when  the  lumbar 
lesions  are  adjusted.  Muscular  overstrain ;  indiscretions  in  diet 
and  habits;  age,  from  fifteen  to  thirty,  are  predisposing  factors. 

Although  the  possibility  of  infection  of  the  appendix  from  the 
ovary  might  be  expected  to  increase  the  relative  number  of  cases 
of  appendicitis  occurring  in  women,  and  although  women's  dress 
is  such  as  might  be  expected  to  favor  diseases  of  the  appendix,  as 
of  other  abdominal  viscera,  yet  about  three  times  as  many  appendix 
cases  occur  in  men  as  in  women.  This  is  probably  due  to  the 
better  circulation  of  the  blood  and  the  better  lymph  drainage  in 
women,  by  way  of  the  ovarian  relations.  This  consideration  shows 
the  tremendous  importance  of  proper  circulation  and  drainage  in 
the  prevention  and  cure  of  cjiseases  of  the  appendix,  and  leads  to  a 
better  understanding  of  the  importance  of  correct  osteopathic  treat- 
ment in  this  disease. 

The  pathologic  anatomy  is  described  when  the  kinds  of  inflam- 
mation are  mentioned :  catarrhal,  which  may  become  chronic  or 
produce  a  fibrous  appendix;  phlegmonous;  ulcerative;  or  gangren- 
ous. 


96  INTESTINAL  INFLAMMATIONS 

Diagnosis.  The  attack  may  be  ushered  in  with  several  days  of 
digestive  disturbance  and  colicky  pains  or  may  appear  suddenly, 
particularly  after  a  full  meal.  The  most  characteristic  symptoms 
are  as  follows :  Pain  is  at  first  over  the  whole  abdomen  but  is  soon 
localized  in  the  right  iliac  fossa.  Tenderness  is  soon  present, 
usually  greatest  at  McBurney's  point.  Rigidity  of  the  right  rectus 
muscle  is  often  replaced  in  two  to  three  days  by  an  oval  tumor 
about  the  size  of  a  hen's  egg.  The  patient  assumes  a  characteristic 
posture,  lying  on  his  back  with  the  right  leg  drawn  up.  Elevation 
of  temperature  is  typical,  102°  to  104°  F. ;  a  fulminating  type  may 
succumb  before  much  fever  appears.  The  gangrenous  type  usually 
has  a  normal  or  subnormal  temperature.  General  symptoms  of 
furred  tongue,  constipation,  vomiting  which  varies  and  is  not 
excessive  and  not  fecal,  and  a  full  and  strong  pulse  are  present  in 
typical  cases; 

If  the  attack  is  light,  the  pain,  tenderness,  and  fever  lessen 
about  the  third  day  and  the  illness  is  over  in  about  a  week,  fol- 
lowed by  complete  recovery.  Recurrent  attacks  vary  from  rare 
ones  to  those  rapidly  repeated.  Chronic  appendicitis  may  follow 
acute  attacks. 

If  recovery  does  not  begin  before  the  sixth  day,  a  local  abscess 
is  probably  forming.  The  fever  continues  or  increases,  becoming 
of  a  septic  type;  the  swelling  is  larger,  harder  and  more  tender; 
but  fluctuation  is  rarely  obtainable.  The  general  symptoms 
become  more  severe.  The  abscess  may  rupture  and  produce  a 
diffuse  peritonitis;  or  may  be  walled  off  and  rupture  into  the 
intestine,  vagina,  the  lumbar  region,  liver,  or  around  the  kidney, 
or  they  may  become  very  well  walled  off  by  adhesions  and  set  up 
only  a  localized  peritonitis.  Perforation  into  the  peritoneum  from 
either  ulceration  or  gangrene  is  indicated  by  a  sudden  fall  in 
temperature,  the  other  symptoms  remaining  grave,  followed  by 
collapse,  or  signs  of  general  peritonitis. 

The  lower  ribs  are  nearly  always  found  depressed,  in  some 
cases  so  much  so  that  the  floating  ribs  seem  to  ride  the  ilium.  The 
tenth  thoracic  to  third  lumbar  vertebral  lesions  are  constant.  The 
tenth  and  eleventh  ribs  on  the  right  side  are  especially  to  be 
examined.  There  may  be  some  interference  with  the  vagi.  The 
cervical  muscles  are  often  contracted.  The  clavicles  and  first  ribs 
may  be  subluxated. 

The  percussion  note  is  changed  in  comparison  with  the  opposite 
side  and  changes  during  the  course  of  the  disease,  being  of  a  dull 
tympanitic  tone  or  a  distinct  area  of  dullness. 

The  urine  is  febrile  in  character  with  large  quantities  of  indi- 
can.  The  blood  shows  leucocytosis.  A  leucocyte  count  of  20,000 
is  high  and  indicates  an  acute  appendicitis,  with  pus,  gangrene,  or 
peritonitis.  In  old  cases  there  is  moderate  leucocytosis  although 
a  normal  count  may  be  present  in  a  walled-off  abscess.     The 


APPENDiariS  97 

erythrocytes  are  not  changed  except  in  cases  of  long  standing 
abscess  when  there  is  anemia. 

Care  must  be  taken  to  differentiate  acute  enteritis,  mucous 
colitis,  intestinal  obstruction,  cholecystitis,  renal  colic,  salpingitis, 
typhoid  fever,  malaria,  ectopic  gestation,  and  lead  poisoning. 

PSEUDO-APPENDICITIS.  This  term  is  applied  by  J.  F.  McNary  to 
a  condition  found  simulating  appendicitis.  The  twelfth  dorsal,  the  twelfth  rib, 
and  muscles  attached  to  it,  and  the  sub-costal  nerve  are  the  seat  of  irritation; 
the  rectus  muscle  is  relaxed ;  by  grasping  the  abdominal  wall  over  the  cecum 
with  pressure,  pain  is  produced;  but,  bearing  down  upon  the  cecum,  pain  is  not 
produced ;  the  appendix  is  not  diseased,  though  the  cecum  may  be  impacted, 
and  elevated  temperature,  accelerated  pulse,  nausea,  and  constipation  may  be 
present. 

Treatment.  Absolute  rest  in  bed,  when  symptoms  resembling 
those  of  appendicitis  occur,  is  the  only  safe  procedure.  If  further 
examination  giv.es  another  diagnosis,  no  harm  is  done  by  the  rest, 
in  any  case. 

As  soon  as  is  possible,  a  blood  examination  should  be  made; 
this  is  for  the  sake  of  securing  correct  data  for  later  study,  as 
well  as  for  the  useful  information  thus  secured  at  the  time. 

It  is  generally  recognized  that  surgery  is  contra-indicated 
during  the  time  of  beginning  abscess.  (The  "early  operation"  is 
performed  before  abscess  formation  occurs — first  to  third  day,  for 
example.)  After  pus  begins  to  be  formed,  no  surgery  should  be 
attempted  until  the  abscess  becomes  circumscribed;  many  sur- 
geons prefer  then  to  await  recovery  from  the  acute  attack.  Before 
the  third  day,  the  propriety  of  surgery  is  doubtful,  since  the  diag- 
nosis is  usually  doubtful.  From  the  first  to  the  third  day,  if  sur- 
gery is  not  performed,  and  from  the  third  day  until  recovery  or 
the  appearance  of  more  serious  symptoms,  gives  the  time  for  the 
use  of  nonsurgical  measures. 

Any  case  of  appendicitis  is  potentially  surgical.  It  should  be 
a  routine  procedure  to  have  everything  in  readiness  for  surgery 
at  a  moment's  notice.  If  a  conservative  surgeon  can  be  seen  in 
consultation  this  is  the  best  possible  thing;  the  opinion  of  the  sur- 
geon who  has  his  knife  always  ready  is  of  no  value.  Surgery 
should  not  be  employed  when  the  case  is  complicated  with  certain 
constitutional  diseases,  diabetes,  nephritis  or  cardiac  disease,  nor 
during  the  early  stages  of  pus  formation. 

Rapid  leucocytosis  indicates  pus  formation,  and  should  lead 
to  great  care ;  surgery  may  be  suddenly  necessary. 

Sudden  rise  of  temperature  indicates  increasing  inflammatory 
process;  sudden  drop  in  temperature  may  indicate  gangrene  or 
rupture  of  an  abscess.  Rigor  and  chilling,  profuse  sweating, 
diarrhea,  vomiting,  collapse,  may  be  associated  with  rupture  of  the 
pus  into  the  abdomen  or  elsewhere.  Relief  of  the  pain  may  indicate 
gangrene,  especially  when  the  constitutional  symptoms  remain 
serious. 


98  INTESTINAL  INFLAMMATIONS 

"Colitis  follows  appendectomy  more  frequently  than  other  abdominal 
operation.  The  explanation  is  that  the  appendicitis  is  seldom  localized  in  the 
appendix  but  is  complicated  by  colitis,  or  rather,  the  colitis  is  complicated  by 
the  appendicitis.  In  such  case,  removal  of  the  appendix  aggravates  rather  than 
alleviates.  A  conclusion  to  be  drawn  is,  to  carefully  palpate  the  colon  in 
appendicitis  cases  and  reserve  diagnosis,  prognosis  and  the  advising  of  an  opera- 
tion until  it  can  be  definitely  determined  as  to  the  location,  extent  and  degree 
of  the  disease.  The  formation  of  pus  is  an  indication  requiring  immediate 
evacuation. 

"If  good  surgical  advantages  are  available  and  the  case  begins  with  con- 
siderable virulence  and  a  surgeon  can  be  had  within  the  first  twenty-four  hours, 
it  is  in  all  probability  best  to  operate;  but  if  the  case  begins  slowly  or  no 
good  hospital  advantages  are  available,  or  if  the  case  is  not  seen  until  some 
forty-eight  hours  have  elapsed  after  the  onset,  in  all  probability  it  is  strictly 
an  osteopathic  case  and  should  not  be  touched  by  surgery.  Some  advo- 
cate waiting  in  all  instances  until  pus  is  formed  before  operative  procedure  is 
resorted  to.  This  is  rather  a  dangerous  attitude  to  take,  for  I  have  seen  hun- 
dreds of  cases  operated  and  have  operated  upon  a  great  many  myself  and  I 
have  never  seen  a  case  die  except  it  was  a  pus  case.  Every  clean  case  recovered 
from  the  operation." — S.  L.  Taylor. 

Without  disturbing  the  patient  more  than  very  slightly,  it  is 
possible  to  secure  thorough  relaxation  of  the  tissues  found  con- 
tracted along  the  spinal  column  and  through  the  cervical  region. 
If  the  clavicles  and  upper  ribs  are  subluxated,  these  may  be  cor- 
rected. The  vertebrae  should  be  examined,  and  the  possibility  of 
intervertebral  movement  secured  throughout.  Deep,  steady  pres- 
sure may  relieve  the  pain  of  the  corrective  treatment.  All  manip- 
ulations should  be  very  gently  given,  in  order  to  prevent  sending 
irritating  sensory  impulses  into  the  spinal  or  bulbar  nerve  centers. 

Having  eliminated  the  presence  of  pus,  by  physical  examina- 
tion, symptoms,  and  the  lack  of  leucocytosis,  local  manipulation 
can  be  given.  The  patient  is  turned  upon  the  right  side,  or  in 
the  right  lateral  position,  or  semiprone,  and  the  tissues  around  the 
cecal  region  lifted  and  gently  drawn  upward.  The  tissues  may 
also  be  grasped  very  gently,  and  pushed  toward  the  painful  area. 
The  patient  may  lie  in  this  position  for  a  time,  if  comfortable; 
changing  position  gives  better  circulation  and  drainage,  generally. 
But  this  performance  is  absolutely  contraindicated  if  there  is  the 
least  possibility  of  pus  formation.  Such  treatment,  given  during 
an  early  stage  of  pus  formation,  might  lead  to  serious,  even  fatal, 
results. 

Treatments  should  be  given  from  once  to  three  times  each  day, 
during  the  first  week;  from  three  times  to  once  a  week  during 
improvement  and  convalescence.  Too  speedy  cessation  of  treat- 
ment may  permit  recurrence  or  a  chronic  condition ;  also  the  per- 
sistence of  bony  lesions  which  may  lead  to  other  gastro-intestinal 
disorders,  later. 

In  the  beginning,  the  colon  should  be  cleansed  thoroughly. 
This  is  to  be  done  by  enemas  of  water,  salt  solution,  warm  olive 
or  other  oil.   It  is  necessary  simply  to  wash  the  tolon.   Absolutely 


APPENDICITIS  99 

nothing  irritating  should  be  used  for  this  purpose,  either  as  enema 
or  as  purgative  medicines.  The  use  of  purgative  medicines  is 
doubtless  responsible  for  many  fatalities,  and  increases  the  neces- 
sity for  surgery.  Members  of  the  family  must  be  obedient  in  this 
respect — too  often  purgative  medicines  are  given  disobediently. 

Do  not  permit  opiates  to  be  given. 

No  food  is  to  be  given.  Water  is  supplied  through  the 
enemas ;  this  is  absorbed  from  the  mucous  membrane.  The  mouth 
may  be  often  washed  with  cool  water;  a  very  little  lemon  juice  or 
pineapple  juice  may  be  comfortable,  but  cool  water  is  usually 
most  grateful.  After  the  danger  of  pus  formation  has  passed, 
small  amounts  of  liquids  may  be  permitted,  and  the  return  to 
normal  foods  made  very  slowly.  A  week  or  more  of  fasting,  fol- 
lowed by  a  week  or  two  of  liquid  diet  (milk,  fruit  and  vegetable 
juices,  albumen  water  and  broths)  leaves  the  patient  with  greater 
strength  and  opportunity  for  more  rapid  recovery  than  the  dan- 
gerous use  of  greater  range  of  diet.  When  the  lack  of  food  seems 
to  cause  much  feeling  of  weakness,  rectal  feeding  may  be  resorted 
to ;  rubbing  the  limbs  with  oils  gives  a  pleasant  sense  of  increased 
strength,  and  while  it  is  not  probable  that  any  absorption  occurs, 
yet  patients  feel  better  for  this  massage.  Any  nurse  can  do  this 
work  over  the  limbs  several  times  a  day,  if  necessary. 

Heat  and  cold  relieve  the  pain  considerably.  Hot  water  bottles 
should  be  partly  filled  and  the  air  forced  out,  in  order  to  make 
them  light  in  weight  and  not  noisy.  An  electric  pad  is  very  con- 
venient, but  must  usually  be  watched  to  prevent  burning;  these  are 
sometimes  supplied  with  a  safety  device  which  makes  them  self- 
regulating,  but  even  then  they  should  be  watched.  Hot  compresses 
may  relieve  when  dry  heat  is  useless.  Mustard  plasters  may  relieve 
the  pain,  but  they  must  not  be  allowed  to  injure  the  skin.  Blisters 
are  probably  best  omitted. 

For  cold,  ice  bags,  made  light  in  weight,  are  probably  best. 
A  water  bag  containing  a  small  amount  of  cold  water,  often 
replaced,  may  be  most  comfortable.  Cloths  wet  in  icy  water  may 
be  used,  but  this  is  difficult  to  manage  at  home.  A  large  ice  bag, 
suspended  so  that  it  barely  touches  the  skin  but  exerts  no  weight, 
is  perhaps  the  most  pleasant  way  of  applying  cold. 

A  small  sand-bag,  either  hot  or  cold,  placed  under  the  dorso- 
lumbar  spinal  column,  gives  relief  in  some  cases.  Either  heat  or 
cold,  applied  to  the  spinal  region  of  most  marked  muscular  ten- 
sion or  of  greatest  sensitiveness,  exerts  a  reflex  effect  upon  the 
pain  in  the  abdomen. 

Sometimes  the  skin  over  the  appendix  has  been  blistered, 
or  burned  by  **home  remedies";  in  such  cases  heat  or  cold  may 
be  applied  over  the  spinal  areas,  or  over  the  lower  ribs,  or  around 
the  groin  with  great  relief. 


100  INTESTINAL  INFLAMMATIONS 

"Spinal  treatment  depends  upon  location  of  reflex  muscular  contractions 
and  painful  areas;  should  be  given  once  to  three  times  each  day  at  first,  until 
pain  diminishes,  which  should  be  in  one  to  three  days." — R.  D.  Emery. 

"In  all  cases  of  appendicitis,  there  is  much  contraction  in  the  right  side, 
in  the  muscles  of  the  lumbar  region,  and  in  the  muscles  of  the  abdomen,  which 
will  draw  the  right  iliac,  and  the  right  innominate,  so  that  there  will  appear  to 
be  an  innominate  lesion,  and  when  the  irritation  is  relieved,  the  innominate 
lesion  will  disappear." — T.  L,.  Ray. 

Prognosis.  In  non-suppurative  cases,  either  with  or  without 
surgery,  recovery  is  the  rule.  In  suppurative  cases,  with  surgery, 
the  mortality  varies. 

There  is  great  liability  to  recurrences.  To  prevent  such,  the 
most  careful  attention  must  be  given  to  the  diet,  to  exercises  to 
prevent  constipation,  to  all  means  of  promoting  good  circulation 
and  drainage  of  the  entire  abdomen  by  having  thorough  treatment 
to  keep  the  blood  and  nerve  supply  in  the  best  possible  condition. 

Sequelae.  Repeated  attacks  result  in  increased  adhesions,  oblit- 
eration of  the  appendix  and  ultimate  recovery ;  but  in  any  one. 
attack,  abscess  or  peritonitis  may  occur ;  or  the  mass  of  adhesions 
cause  poor  circulation  and  impaired  function  of  the  bowels;  or  a 
train  of  ill-health  with  ill-defined  digestive  disorders. 

The  removal  of  the  appendix  in  such  cases  is  a  matter  requiring 
consideration,  since  it  is  difficult,  even  with  the  fluoroscope,  to 
know  the  extent  and  nature  of  the  old  adhesions,  or  whether  the 
new  adhesions,  resulting  from  the  removal  of  the  appendix,  will  be 
greater  or  less  than  those  already  present. 


CHRONIC  ENTERO-COLITIS  OF  ADULTS 

(Chronic  diarrhea;  mucous  colitis;  chronic  colitis) 

This  is  not  a  very  common  disease,  in  its  noninfectious  form. 
It  is  usually  the  sequence  of  repeated  attacks  of  acute  entero- 
colitis or  of  the  constant  effects  of  bony  lesions  or  irritants. 

The  symptoms  are  those  of  intermittent  or  remittent  diarrhea, 
with  stools  covered  with  mucus,  or  followed  by  strings  or  masses 
of  mucus,  both  during  the  diarrheal  attacks  and  in  the  intervals. 
This  passing  of  mucous  stools  in  the  intervals  of  the  attacks  is  the 
most  trustworthy  diagnostic  symptom.  Sometimes  in  the  exacer- 
bations rather  large  amounts  of  blood  may  be  passed,  more  rarely 
shreds  of  membrane.  Griping  and  colicky  pains  may  be  asso- 
ciated with  the  diarrheal  passages. 

Chronic  colitis  of  a  rather  persistent  type  has  been  found  due 
to  the  constant  use  of  irritating  enemas.  For  example,  the  use 
of  strong  salt  solution,  water  with  large  amounts  of  impure  or 
alkali-bearing  soaps,  very  hot  or  very  cold  water,  and  solutions 
of  Epsom  and  other  purgative  salts,  are  often  used.     It  is  a  not 


PROCTITIS  101 

unusual  practice  for  patients  to  work  for  the  elimination  of  the 
mucus,  under  the  idea  that  relief  is  thus  obtained. 

The  treatment  and  prognosis  depend  upon  the  causes  of  the 
irritation.  When  these  factors  can  be  eliminated,  recovery  is 
usually  speedy. 

Strong  corrective  treatment,  given  through  the  lower  thoracic 
and  upper  lumbar  region,  securing  increased  mobility  of  each 
articulation  of  vertebra  and  ribs,  raising  the  ribs  thoroughly,  and 
such  other  corrections  as  may  be  indicated  in  each  case,  usually 
relieves  the  attacks.  With  continued  treatment,  recovery  is  often 
complete. 

Dietetic  error  should  be  corrected;  no  food  should  be  given 
during  an  acute  attack. 

Chronic  Dysentery,  see  Acute  Infectious  Diseases. 

PROCTITIS 

(Catarrh  of  the  rectum;  dysentery;  rectitis) 

Proctitis  is  an  inflammation,  usually  catarrhal,  of  the  mucous 
membrane  of  the  rectum  and  anus,  characterized  by  pain,  tenesmus, 
and  frequent  stools  of  hardened  feces  or  of  mucus,  pus  and  blood. 

The  causes  are  constipation,  improper  use  of  enemas  and 
habitual  use  of  purgatives,  diseases  of  the  liver,  hemorrhoids,  sit- 
ting upon  the  damp  ground  or  cold  places,  and  lesions  in  the  lumbo- 
sacral, sacral  or  coccygeal  regions  of  the  spine. 

Diagnosis.  There  is  a  sudden  onset  with  chill,  general  malaise, 
slight  fever,  pain  and  discomfort,  increasing  to  a  burning  pain  in 
the  rectum  which  radiates  to  the  adjacent  parts,  a  sense  of  fullness 
and  weight  in  the  rectum,  the  passage  of  hardened  feces,  later 
mucus,  muco-pus,  or  blood ;  tenesmus ;  the  bladder  may  be  irritable ; 
the  mucous  membrane  may  prolapse,  and  general  symptoms  of 
headache,  and  nausea  appear.  The  patient  usually  prefers  the 
recumbent  position.  In  severe  cases,  strangury  and  vesical  tenes- 
mus may  complicate  the  case.  Peritonitis  and  hepatic  abscess  may 
occur. 

If  the  case  is  protracted,  periproctitis  and  fistulas  may  develop. 
If  periproctitis  supervenes,  it  is  indicated  by  a  thin  fecal  discharge 
at  first,  then  followed  by  mucus  tinged  with  blood.  Ulceration 
soon  follows.  The  parts  are  hot,  dry,  swollen,  and  digital  exam- 
ination is  very  painful.  Later,  the  parts  are  slimy  and  the  mucous 
membrane  is  covered  with  tenacious  mucus  and  pus.  If  abscess 
is  present,  there  will  be  a  fluctuating  mass  which  may  show  exter- 
nally or  may  be  felt  by  rectal  touch.  The  use  of  the  rectal  specu- 
lum is  contra-indicated  in  acute,  nonsurgical  cases. 

The  spinal  examination  shows  contractions  of  the  muscles  of 
the  back  from  the  lower  lumbar  to  the  tip  of  the  coccyx.     Bony 


102  INTESTINAL  INFLAMMATIONS 

lesions  are  detected  with  difficulty  on  account  of  these  intense 
muscular  contractions. 

Treatment.  The  first  indication  is  to  remove  the  irritating 
intestinal  contents  by  enema  of  cool  water,  if  the  case  is  seen 
early ;  if  later,  warm  water  is  more  comfortable.  Warm  oil  may  be 
soothing.    The  patient  must  not  be  permitted  to  lie  upon  his  back. 

Attention  should  be  given  to  the  sigmoid  area  to  see  that  it  is 
thoroughly  elevated.  As  soon  as  lesions  can  be  recognized  and 
corrected,  this  should  be  done.  Correction  of  lumbar  and  innomi- 
nate lesions,  after  recovery  from  the  acute  attack,  may  prevent 
recurrence. 

Patients  must  be  guarded  against  sitting  in  cold  places,  strain- 
ing at  stool,  or  standing  for  too  long  periods  for  some  months  after 
an  acute  attack.  Injurious  habits  must  be  corrected ;  these  include 
the  habitual  use  of  dilators,  irritant  enemas,  suppositories  and 
other  improper  methods  for  the  relief  of  constipation. 

The  pain  is  lessened  by  thorough  relaxation  throughout  the 
lower  part  of  the  back  and  buttocks.  This  also  favors  a  better 
circulation  through  the  parts.  Careful  attention  must  also  be 
given  to  the  liver. 

The  diet  must  be  restricted.  If  periproctitis  and  suppuration 
supervene,  or  are  present  when  the  case  is  first  seen,  early  incision 
is  indicated  with  subsequent  drainage. 

Prognosis.  Usually  good  with  proper  treatment.  Chronic 
proctitis,  abscesses  or  fistulse  may  result  from  neglect. 


CHAPTER  IX     . 
DISEASES  OF  THE  LIVER 

ANOMALIES  OF  THE  LIVER 

The  anomalies  in  the  shape  and  position  of  the  liver  must  not  be  forgot- 
ten; in  making  a  diagnosis  of  disease  of  this  organ  one  is  sometimes  confused 
by  the  presence  of  these  anomalies.  Malformations  may  be  either  congenital 
or  acquired.  Those  very  rare  cases  in  which  the  liver  is  found  upon  the  left 
side  of  the  body,  while  the  stomach  and  spleen  are  upon  the  right  side, 
usually  have  only  to  be  examined  to  become  definitely  diagnosed.  Congenital 
absence  of  one  or  more  of  the  lobes,  or,  rather  more  commonly,  an  increased 
number  of  lobes  of  the  liver,  may  cloud  a  diagnosis  under  certain  circumstances. 

Tight  lacing  may  cause  an  almost  complete  separation  of  part  of  the  right 
lobe  from  the  rest  of  the  liver.  This  condition  is  becoming  less  rare  on  account 
of  present  saner  fashions  in  corsets. 

As  the  result  of  the  abnormal  lengthening  of  the  suspensory  ligament  of 
the  liver,  or  as  the  result  of  bands  from  adhesions  and  old  inflammatory 
processes,  the  liver  may  be  lower  than  normal.  Occasionally  the  liver  seems  to 
be  in  an  anomalous  position  on  account  of  spinal  curvature,  especially  when  in 
marked  kyphosis.  The  liver  may  be  displaced  upward  by  the  pregnant  uterus, 
abdominal  tumors  or  cysts,  or  by  considerable  quantity  of  gas  in  the  intestines 
or  in  the  peritoneal  cavity.  Ascites  or  fat  may  push  the  liver  upward  or  some- 
what forward  toward  the  right  side. 

The  liver  may  be  pressed  downward  by  emphysema,  pleurisy  with  eflfusion, 
mediastinal  tumors  or  hypertrophied  heart. 


JAUNDICE 

(Icterus) 

This  is  a  name  applied  to  a  group  of  symptoms  arising  from 
the  presence  of  bile  in  the  circulating  blood,  and  is  clinically  mani- 
fested by  a  yellow  or  greenish-yellow  tint  of  the  skin  and  mucous 
membranes  and  by  pruritus. 

There  are  two  classes  of  symptoms: 

Absence  of  bile  from  the  intestines  interferes  with  perfect  assim- 
ilation of  fat,  delays  absorption,  and  slows  peristalsis,  thus  per- 
mitting putrefactive  changes  in  the  intestinal  contents  and  the 
production  of  toxemic  symptoms.    The  feces  are  pale. 

Circulation  of  bile  within  the  blood  produces  toxic  effects,  both 
upon  the  nerve  cells  and  upon  muscular  fibres,  with  consequently 
impaired  heart  action,  slowness  of  the  pulse,  depression  of  spirits 
and  mental  torpidity;  various  tissues  and  secretions  become  bile- 
stained. 

Etiology.  Obstructive  jaundice  is  caused  by  foreign  bodies 
within  the  duct,  such  as  gall-stones,  hydatids,  or  distomata ;  or  by 
foreign  bodies  from  the  intestine,  inflammation  of  the  duodenum 

103 


104  THE  LIVER 

or  mucosa  of  the  duct  or  by  stricture  or  obliteration  of  the  duct, 
or  by  tumors,  fecal  accumulations,  or  pregnancy. 

Non-obstructive  jaundice  may  be  caused  by  poisons  in  the 
blood  interfering  with  the  normal  metamorphosis  of  bile  (toxe- 
mic jaundice),  as  in  various  fevers;  animal  poisons  as  snake 
venom;  chemical  poisons  as  phosphorus,  mercury,  arsenic,  or 
toluylenediamin ;  chloroform  or  ether;  or  by  poisons  of  obscure 
infective  origins,  acute  yellow  atrophy  of  the  liver  and  Weil's  dis- 
ease (epidemic  jaundice). 

Diagnosis.  The  most  conspicuous  symptom  is  icterus  or  tint- 
ing of  the  skin,  conjunctivae,  mucous  membranes,  and  secretions; 
the  color  varying  from  a  lemon-yellow  to  a  deep  greenish-black 
(black  jaundice)  ;  the  urine  and  sweat  are  tinted  while  the  saliva, 
milk,  and  sputum  usually  escape.  Xanthopsy  (yellow  vision)  is 
sometimes  present.  Gastric  disturbances  may  precede  the  jaundice. 
Flatulence,  nausea,  and  often  complete  anorexia  are  common. 
Constipation  often  alternates  with  diarrhea  ;  the  feces  are  pale, 
intensely  fetid  and  pasty.  The  pulse  is  slower  than  normal,  occa- 
sionally twenty  per  minute.  Respirations  may  fall  tt)  ten  per  min- 
ute. Extravasations  of  blood  and  hemorrhages  may  occur  from 
the  mucous  surfaces  or  into  the  skin.  The  coagulability  of  the 
blood  is  diminished. 

Among  the  cerebral  symptoms  may  be  noted  marked  depres- 
sion of  spirits,  melancholia  and,  in  the  grave  cases,  coma  which 
may  end  in  death.  Itching  of  the  skin  may  be  most  distressing. 
The  urine  contains  bile  pigments  and  bile  acids.  The  blood  may 
show  slight  or  marked  changes.  Fragmentation  of  all  cells  is  com- 
mon. In  catarrhal  jaundice,  there  may  be  slight  leucocytosis  at 
the  onset.  The  plasma  of  the  blood  is  bile  stained.  The  coagula- 
tion time  is  slow.  In  toxic  jaundice,  the  red  cells  are  sometimes 
increased ;  the  hemoglobin  is  somewhat  reduced ;  and  the  leuco- 
cytes are  normal  or  increased.  In  severe  cases,  there  is  hemo- 
globinemia  and  many  "blood  shadows"  are  to  be  found.  Leuco- 
cytes show  the  effects  of  the  toxin. 

Hereditary  Icterus.  The  jaundice  is  slight,  the  stools  are  not 
clay-colored ;  splenic  enlargement  is  marked ;  the  general  health  is 
not  much  impaired.  In  another  group  of  cases,  there  is  enlarge- 
ment of  the  liver  and  spleen  and  marked  constitutional  disturb- 
ance, with  only  slight  jaundice. 

Icterus  Neonatorum.  This  form  of  jaundice  occurs  among  the 
new-born  and  may  be  mild  or  severe  in  type. 

The  mild  type  appears  on  the  second  or  third  day  and  lasts  from 
seven  to  fourteen  days,  presenting  few  symptoms  beside  the 
jaundice  and  the  pale  stools.  Nothing  more  th^  the  ordinary 
hygienic  care  of  the  infant  is  needed.    It  is  possibly  due  to  the  large 


HYPEREMIA  105 

destruction  of  red  corpuscles  which  takes  place  in  the  first  few- 
days  after  birth,  or  to  the  patency  of  the  ductus  venosus,  allowing 
the  portal  blood  to  mix  with  the  systemic  blood. 

The  severe  form  is  due  to  congenital  absence  of  the  hepatic 
duct,  congenital  syphilitic  hepatitis,  or  phlebitis  of  the  umbilical 
vein.    It  is  invariably  fatal. 

Treatment  of  Jaundice.  Find  the  cause  and  remove  it  if  pos- 
sible. (See  Gall-stones.)  Correct  subluxations  of  the  vertebrae 
and  ribs  from  the  fifth  dorsal  to  the  first  lumbar.  The  bowels  must 
be  kept  active  by  treatment  and  exercise.  The  diet  should  be  light, 
and  easily  digested,  consisting  of  fruit,  vegetables  and  milk. 

-  The  itching,  if  not  relieved  by  the  treatment,  may  be  alleviated 
by  warm  baths.  Carbolic  lotion  (1:40)  may  be  used  in  severe 
cases. 

Prognosis.  The  outlook  depends  upon  the  cause  of  the  jaundice. 
In  acute  yellow  atrophy  (q.  v.)  a  fatal  termination  is  to  be  ex- 
pected; this  'is  also  the  case  in  the  jaundice  due  to  malignant 
neoplasms.  Nearly  all  living  cells  are  injured  by  bile;  they  recover 
their  normal  function,  if  at  all,  only  after  the  removal  of  the  bile 
from  their  vicinity.  Nervous  symptoms  often  persist  for  some 
weeks  after  the  skin  becomes  clear,  and  these  are  apt  to  recur  on 
fatigue  or  indigestion  for  several  months  after  other  symptoms  of 
jaundice  have  disappeared. 


HYPEREMIA  OF  THE  LIVER 

(Congestion  of  the  liver;  torpid  liver;  biliousness) 

This  is  characterized  by  an  abnormal  fullness  of  the  vessels  of 
the  liver  with  consequent  enlargement,  slowness  of  the  digestive 
and  mental  functions,  and  slight  jaundice. 

Etiology.  Active  hyperemia  is  caused  by  too  great  heat; 
habitual  constipation;  excesses  in  eating  and  drinking;  use  of  alco- 
holic and  malt  liquors ;  and  in  females,  by  arrested  menstrual 
period.  It  is  sometimes  a  complication  of  the  acute  infections. 
Bony  lesions  of  the  sixth  to  the  eleventh  thoracic  vertebrae  and  the 
sixth  to  the  twelfth  ribs  are  important  in  etiology.  Passive  hype- 
remia is  due  to  cardiac  and  pulmonary  disease. 

Pathology.  The  liver  is  enlarged  in  all  directions  and  is  abnormally  full 
of  blood.  In  cases  due  to  obstructive  diseases  of  the  heart  and  lungs,  it  presents 
the  "nutmeg  liver"  appearance.  The  dilated  radicles  of  the  hepatic  veins  with 
pallor  of  the  neighboring  parts  of  the  lobule  are  noted.  Long-continued  con- 
gestion leads  to  atrophic  degeneration  or  to  cyanotic  induration. 

Diagnosis.  The  symptoms  of  active  hyperemia  include  malaise, 
aching  of  the  limbs,  very  slight  fever,  headache,  mental  depression, 
coated  tongue,  anorexia,  nausea  and  sometimes  vomiting,  constipa- 
tion and  flatulence,  a  feeling  of  weight  and  soreness  in  the  liver 


106  THE  LIVER 

area  with  a  dull  pain  extending  to  the  right  shoulder.  The  liver 
is  uniformly  enlarged  and  tender,  the  complexion  is  muddy  and 
there  may  be  slight  jaundice. 

In  passive  hyperemia  the  symptoms  are  much  like  the  above 
but  less  severe.  The  onset  is  gradual  and  gastrointestinal  catarrh 
is  common.  In  addition,  there  are  the  symptoms  of  the  causal  dis- 
ease. If  the  hyperemia  is  due  to  incompetency  of  the  tricuspid 
valve,  the  whole  organ  may  pulsate. 

Treatment.  Thorough  direct  manipulation  to  the  liver  by  rais- 
ing and  spreading  the  ribs  facilitates  drainage.  All  subluxations 
which  might  bear  a  causal  relation  to  disturbances  of  the  hepatic 
circulation  must  be  corrected.  A  scanty  diet  of  easily  digested 
foods  with  an  absence  of  sugars  and  fats,  as  far  as  possible,  is 
usually  best.  If  the  pain  is  severe,  hot  applications  may  be  used 
over  the  liver  region,  or  a  heating  compress  may  be  applied.  The 
bowel  action  must  not  be  permitted  to  become  sluggish. 

The  passive  form  requires,  in  addition,  the  treatment  of  the 
primary  disease. 

Prognosis.  An  attack  of  active  hyperemia  usually  lasts  about 
a  week,  ending  in  recovery.  If  a  constant  repetition  of  attacks 
occurs,  atrophic  degeneration  is  usual.  The  prognosis  in  passive 
hyperemia  depends  entirely  upon  the  nature  and  curability  of  the 
primary  disease. 

ACUTE  YELLOW  ATROPHY 

(Icterus  gravis;  acute  or  general  parenchymatous  hepatitis;  hemorrhagic  icterus; 
malignant  or  infectious  jaundice) 

An  acute,  general  inflammation  of  the  hepatic  cells  resulting  in 
their  rapid  disintegration  and  characterized  by  decreased  size  of 
the  liver,  deep  jaundice,  hemorrhages  and  profound  cerebral  symp- 
toms. 

Etiology.  The  disease  is  apparently  due  to  some  toxic  agent 
circulating  in  the  blood.  It  occurs  most  frequently  in  young  preg- 
nant women  from  the  third  to  the  sixth  month  of  gestation.  Among 
the  other  causes  are:  Infectious  diseases,  preexisting  disease  of 
the  liver,  alcoholic  and  venereal  excesses,  syphilis,  poisoning  by 
phosphorus,  arsenic,  or  antimony,  and  sometimes  fright  or  pro- 
found mental  emotion.  Chloroform  anesthesia  is  usually  consid- 
ered doubtful.  In  one  P.  C.  O.  clinic  patient  this  seemed  to  be  the 
only  cause. 

Pathology.  The  early  hyperemia  of  the  hepatic  cells  with  a  grayish  exu- 
dation between  the  lobules  soon  produces  a  soft,  friable  organ  of  a  dull  yellow 
color;  the  cells  rapidly  disappear  and  are  replaced  by  fat  globules;  yellow  and 
red  atrophic  patches  are  found,  while  granules  of  pigment  and  crystals  of 
leucin  and  tyrosin  are  seen  microscopically ;  the  whole  organ  is  reduced  in 
size  and  weight,  the  peritoneal  covering  being  loose  and  wrinkled.    The  spleen, 


YBLLOW  ATROPHY  107 

kidneys,  heart,   and  muscles  undergo  parenchymatous  degeneration  and  show 
bile-staining. 

Diagnosis.  The  prodromal  symptoms  are  mental  and  bodily- 
depression,  constipation,  gastrointestinal  catarrh,  tenderness  of  the 
liver  region,  quickened  pulse,  headache,  and  slight  jaundice  with 
moderate  itching.     These  may  continue  from  one  to  three  weeks. 

The  confirmed  stage  is  indicated  by  deepened  jaundice,  usually 
rapid  pulse,  persistent  headache,  and  insomnia,  persistent  vomit- 
ing, cerebral  symptoms,  and  trembling  of  the  muscles.  As  a  rule, 
there  is  no  fever,  though  it  may  be  severe,  perhaps  to  106°  F.  The 
tongue  is  dry  and  coated.  Delirium  and  convulsions,  abdominal 
pain,  hemorrhages  from  mucous  surfaces  and  into  the  skin,  "cof; 
fee-ground"  vomit,  tarry  or  pale  stools,  all  follow  rapidly.  Preg- 
nant women  abort,  often  with  severe  hemorrhage;  this  does  not 
interfere  with  the  course  of  the  disease  to  its  fatal  termination. 
The  typhoid  state  ushers  in  the  end  which  may  come  within  a  week 
or  may  be  prolonged  for  two  or  three  weeks. 

The  area  of  liver  dullness  diminishes  rapidly  and  may  ultimately 
disappear.  There  is  pitting  in  the  epigastrium;  the  spleen  is  en- 
larged. The  spinal  tissues  are  extremely  hypersensitive ;  the  usual 
palliative  manipulations  were  absolutely  inefficient  in  one  P.  C.  O. 
clinic  case. 

Urine  shows  diminished  quantity;  strongly  acid  reaction;  noi- 
mal  solids  diminished;  leucin,  tyrosin  and  other  abnormal  nitrog- 
enous compounds  are  usually  present.  The  albuminuria,  casts  and 
renal  epithelium  are  due  to  the  associated  nephritis. 

Moderate  leucocytosis  with  blood  otherwise  normal  is  recorded. 
Usually  all  blood  cells  show  the  effects  of  the  poison ;  erythrocytes 
are  vacuolated  and  often  fragmented ;  lymphocytes  contain  gran- 
ules, have  aberrant  nuclear  forms,  and  irregular  protoplasmic  out- 
lines ;  the  neutrophiles  are  most  profoundly  modified,  having  eccen- 
tric or  extruded  nuclei,  vacuolated  protoplasm  and  nuclei,  ragged 
outlines,  and  other  signs  of  the  effects  of  some  intense  poison. 

Treatment.  Palliative  measures  are  indicated.  The  ice  cap 
may  relieve  the  convulsions  or  delirium.  Subcutaneous  injections 
of  normal  salt  or  the  use  of  the  Murphy  drop  method  may  relieve 
the  toxemia.  Correction  of  the  lesions  as  found,  raising  of  the 
lower  ribs  should  be  a  part  of  the  treatment.  Careful  study  of  every 
patient  should  be  made,  in  the  hope  of  securing  knowledge  that 
leads  to  better  prophylactic  and  therapeutic  methods  than  we  now 
possess.  Pregnant  women  with  history  of  individual  or  family 
tendency  to  hepatic  disturbances  should  be  very  closely  watched. 

Prognosis.  Typical  cases  always  terminate  fatally;  atypical 
cases,  in  whom  the  tissue  destruction  is  absent  or  slight,  may 
recover,  after  long  and  tedious  illness.  Pregnant  women  abort, 
which  does  not  affect  the  prognosis. 


108  THB  LIVER 

INTERSTITIAL  HEPATITIS 

(Cirrhosis  of  the  liver;  sclerosis  of  the  liver) 

Interstitial  hepatitis  is  a  chronic  inflammatory  disease  of  the 
liver  characterized  by  overgrowth  of  its  connective  tissues,  and 
symptoms  referable  to  the  effects  produced  upon  the  liver  cells  and 
the  bile  capillaries  by  this  pressure.  Three  classes  are  recognized 
which  vary  slightly  in  pathology  and  in  symptoms  but  whose  treat- 
ment and  prognosis  are  very  much  alike. 

When  the  portal  circulation  becomes  obstructed,  a  collateral 
circulation  is  established  by  way  of  anastomosis  between  the 
branches  of  the  portal  vein  and  the  systemic  veins.  The  anasto- 
moses which  are  most  frequently  efficient  are  those  between  the 
gastric  and  the  esophageal  veins ;  the  veins  of  the  intestines  and, 
the  retro-peritoneal  veins ;  the  portal  vein  with  the  epigastric 
(hence  the  caput  medusae),  and  the  superior  hemorrhoidal  of  the 
inferior  mesenteric  vein  with  the  inferior  and  middle  hemorrhoidals 
of  the  internal  iliac  vein.  These  anastomotic  veins  become  greatly 
dilated  in  the  presence  of  hepatic  cirrhosis  and  the  circulation  thus 
established  may  be  so  efficient  in  some  cases  that  practically  no 
symptoms  are  produced.  The  caput  medusae,  the  dilated  super- 
ficial abdominal  veins  and  the  hemorrhoids  usually  lead  to  a  sus- 
picion of  the  hepatic  obstruction.  Several  types  of  interstitial  hepa- 
titis are  recognized. 

ALCOHOLIC  CIRRHOSIS 

(Laennec's  cirrhosis ;  drunkard's  liver ;  gin  drinker's  liver ;  hobnailed  liver ;  nut- 
meg liver;  portal-cirrhosis;  atrophic  cirrhosis;  multilocular  cirrhosis) 

In  this  form  of  cirrhosis  the  multiplication  of  the  connective 
tissue  originates  around  the  branches  of  the  portal  vein.  The 
capsule  of  the  liver  is  much  thickened,  the  surface  is  rough  and 
presents  the  "hobnailed"  appearance.  As  the  names  indicate,  the 
condition  is  chiefly  due  to  prolonged  alcoholism,  though  heredity 
and  syphilis  are  certainly  important  etiological  factors;  the  over- 
use of  highly  seasoned  foods  is  also  considered  causative  in  rare 
instances. 

Diagnosis.  "The  onset  is  usually  gradual.  Catarrhal  disturb- 
ances of  the  stomach  and  the  intestines  with  morning  vomiting, 
nausea,  anorexia  and  acid  eructations  usually  lead  to  a  diagnosis 
of  chronic  gastritis  in  the  early  stages.  Epistaxis  may  be  a  rather 
early  symptom;  hemorrhoids,  a  sense  of  weight  or  aching  in  the 
liver  region  or  under  the  right  shoulder  occur  when  the  portal  cir- 
culation becomes  too  greatly  impeded.  Hematemesis  and  tarry 
stools  depend  upon  the  damming  back  of  the  blood  in  the  portal 
vein ;  fever  is  rare ;  the  pulse  is  small  and  rapid  y  emaciation  and 
pallor  may  be  marked  or  may  be  masked  by  the  distention  of  the 


CIRRHOSIS  109 

vessels  in  the  skin  which  is  characteristic  of  the  alcoholic  habit. 
The  skin  is  usually  of  a  sallow  or  putty-like  color;  the  flatulent 
distention  of  the  abdomen  may  be  associated  with  ascites ;  jaundice 
occurs  rather  late  in  the  disease,  if  at  all,  and  is  rarely  pronounced ; 
nervous  symptoms  rarely  appear  before  the  terminal  stages,  with 
the  onset  of  stupor  or  noisy  delirium.  These  symptoms  usually 
terminate  within  a  few  hours  or  a  few  days  in  deep  coma,  which 
in  turn  terminates  by  death  from  exhaustion,  anemia,  or  heart 
failure. 

The  liver  dullness  is  enlarged  at  first;  later,  it  is  markedly 
diminished.  The  "hobnails"  may  be  felt  on  palpation  in  a  very 
thin  patient;  the  splenic  dullness  is  enlarged,  and  "caput  medusae" 
is  present. 

The  urine  is  scanty,  high-colored,  of  increased  density,  loaded 
with  urates ;  the  urea  is  diminished,  and  blood  and  other  pigments 
may  be  present.  The  blood  examination  gives  little  aid ;  early, 
there  is  no  change  in  the  red  cells ;  later,  there  is  slight  anemia. 
The  leucocytes  are  normal  or  low  or  a  moderate  leucocytosis  may 
be  present.    The  blood  cells  may  show  the  effects  of  the  toxemia. 

Treatment.  Structural  perversions  should  be  corrected,  if  the 
condition  of  the  patient  permits — if  the  disease  has  not  already 
passed  the  earlier  stages.    Raising  the  ribs  is  especially  good. 

Alcohol  is  to  be  entirely  discontinued ;  tobacco,  spices,  tea  and 
coffee  are  best  denied.  Excess  of  meat  is  harmful.  Probably  an 
entire  milk  diet  is  best  for  some  days,  or  until  the  digestive  tract 
is  fairly  clean.  Otherwise,  the  diet  should  preferably  be  chiefly 
cellulose — especially  green  vegetables  and  fresh  fruits.  Fats  and 
sugars  are  contra-indicated. 

When  ascites  is  present,  dry  diet,  with  absolutely  no  salt,  is 
advised.  Water  may  be  taken  in  very  tiny  sips,  either  hot  or  cold, 
or  bits  of  ice  may  be  left  to  melt  in  the  mouth.  Massage  and  rub- 
bing keep  the  skin  in  as  good  shape  as  can  be;  the  action  of  the 
kidneys  is  to  be  watched. 

Prognosis.  Recovery  is  not  to  be  expected.  If  the  collateral 
circulation  is  well  established,  the  atrophy  not  marked,  and  the 
patient  willing  to  live  temperately,  serious  symptoms  may  not 
arise  for  a  considerable  time.  In  far-advanced  cases,  the  outlook 
is  grave.  Some  cases  live  two  to  four  years ;  usually  about  a  year 
after  dropsy  occurs. 

BILIARY  CIRRHOSIS 

In  this  disease  the  cirrhosis  is  the  result  of  a  chronic  inflamma- 
tion of  the  bile  ducts.  It  may  originate  from  cholecystitis  and  in- 
vade the  liver  by  extension  from  the  bile  capillaries. 

The  symptoms  are  those  of  chronic  cholecystitis  followed  by  a 
slowly  progressive  cirrhosis  of  the  hypertrophic  type.     Within  a 


no  THE  LIVER 

few  months  the  apparent  hypertrophy  is  followed  by  an  atrophy 
and  the  future  course  of  the  disease  as  well  as  the  treatment  is  very 
much  like  that  in  alcoholic  cirrhosis. 

Bronzed  Diabetes  is  a  rare  disease,  characterized  by  bronzing  of  the 
skin,  marked  glycosuria,  biliary  cirrhosis  of  the  liver,  rapid  cachexia  and 
death.  The  supra-renals  and  the  pancreas  are  also  cirrhotic.  The  diagnosis 
rests  upon  the  bronzing,  glycosuria  and  enlarged,  cirrhotic  liver.  No  treat- 
ment is  of  any  avaiL 

HYPERTROPHIC  CIRRHOSIS 

(Hanot's  disease;  unilobular  cirrhosis) 

This  form  of  cirrhosis  is  characterized  by  the  embryonic  type 
of  the  growth  of  connective  tissue  and  the  very  marked  round  cell 
infiltration  of  the  new  growth.  Atrophy  occurs  rarely  if  ever  in 
this  form;  the  hyperplasia  may  be  extremely  marked. 

Etiology.  This  disease  is  very  rare.  It  mostly  affects  young 
adults  and  children.  Several  members  of  the  same  family  are  fre- 
quently affected.  It  has  no  connection  with  alcoholism.  The 
causative  agent  is  unknown,  but  there  seems  to  be  some  toxin 
which  reaches  the  liver  by  the  general  circulation. 

Diagnosis.  The  onset  is  gradual.  Jaundice  is  very  early  and 
becomes  very  severe.  Hepatic,  splenic,  and  gastro-intestinal  symp- 
toms are  at  first  usually  slight  and  increase  in  severity.  Periodic 
attacks  of  severe  abdominal  pain  with  nausea  and  vomiting  are 
frequent.  Fever,  sometimes  to  104°  F.,  may  accompany  the  pain- 
ful attacks.  The  symptoms  of  obstruction  of  the  portal  vein  do 
not  occur  until  late  in.  the  disease.  The  course  of  the  disease  is 
slow ;  death  results  after  several  years  from  toxemia  or  as  the 
result  of  complications.  The  urine  contains  bile  but  is  otherwise 
fairly  normal.  The  feces  sometimes  are  normal  in  color,  sometimes 
pale  and  are  sometimes  extremely  dark  from  an  excess  of  bile ; 
this  variation  is  diagnostic.  The  blood  shows  a  slight  leucocytosis, 
and  some  signs  of  secondary  anemia.  Nervous  symptoms  are 
severe  and  variable. 

The  symptoms  are  those  of  atrophic  cirrhosis — the  ascites 
requiring  many  tappings.    Jaundice  is  not  often  present. 

Treatment.  It  is  of  prime  importance  that  the  circulation  be 
normalized,  if  at  all  possible,  by  corrective  work  from  the  fifth  to 
twelfth  dorsal  vertebrae.  The  rib  articulations  must  also  be  care- 
fully examined  and  all  mal-adjustments  found ;  these  must  be  cor- 
rected. 

At  first,  the  diet  should  be  restricted  to  milk,  but  as  the  patient 
becomes  better,  other  light,  non-irritating,  nourishing  foods  may  be 
used.  Fatty  and  saccharine  foods  should  be  avoided.  When  there 
is  ascites,  a  dry  diet  without  salt  may  be  tried.    The  bowels  and 


ABSCESS  111 

the  skin  function  must  be  kept  active,  and  the  kidneys  watched 
carefully.  A  quiet,  out-door  life  is  best.  If  all  other  measures  fail, 
tapping  may  be  used  for  relief  of  ascites,  or  Southey's  tubes  may 
be  used. 

Prognosis.  The  outlook  is  unfavorable.  The  course  is  slow  but 
it  is  ultimately  fatal. 

ABSCESS  OF  THE  LIVER 

(Acute  purulent  hepatitis;  parenchymatous  hepatitis;  suppurative  hepatitis) 
This  is  a  diffuse  or  circumscribed  inflammation  of  the  liver  cells, 
due  to  infection  by  the  pyogenic  bacteria,  and  resulting  in  suppura- 
tion. The  abscesses  may  be  multiple  or  single.  The  disease  is 
characterized  clinically  by  irregular  fever,  hepatic  tenderness  and 
aching,  and  symptoms  of  deranged  gastro-intestinal  and  hepatic 
functions. 

Etiology.  Staphylococci,  streptococci,  typhoid  bacilli,  or  any 
other  of  the  usual  pyogenic  or  pathogenic  bacteria  are  direct  or 
indirect  agents.  These  reach  the  liver  by  way  of  the  systemic  or 
the  portal  blood,  by  extension  from  neighboring  viscera,  including 
the  lungs,  by  perforation  of  the  diaphragm,  or  by  way  of  the  bile 
ducts.  Appendicitis,  cholangitis,  phlebitis,  cholelithiasis,  may  give 
origin  to  the  infection.  When  the  infection  is  carried  by  the  portal 
vein,  the  abscesses  are  usually  multiple. 

Bony  lesions  of  the  mid-thoracic  region  and  the  corresponding 
ribs  seem  to  lower  the  resistance  to  infections,  in  general,  and  also 
to  interfere  reflexly  with  the  nervous  and  circulatory  mechanism 
of  the  liver. 

Diagnosis.  There  are  irregular  intermittent  or  remittent  fever, 
chills  and  sweats ;  obstinate  vomiting  and  other  gastro-intestinal 
disturbances ;  constipation  with  light  colored  stools ;  muddy  com- 
plexion with  sometimes  slight  jaundice ;  irritability  of  the  nervous 
system  ;  melancholia ;  anemia ;  leucocytosis ;  and  general  symptoms 
of  pyemia  or,  in  marked  cases,  typhoid  symptoms.  Pain  is  variable 
and  often  referred  to  the  back,  shoulders  or  other  regions.  Dull 
aching  over  the  liver  may  be  noticed. 

Locally,  the  hepatic  enlargement  is  upward,  sometimes  with 
circumscribed  bulging  with  pain,  tenderness  and  fluctuation.  It 
frequently  ruptures  through  the  diaphragm  into  the  lung,  causing 
empyema. 

When  the  abscess  tends  to  burst  externally,  the  skin  over  it  is 
hot,  red,  tender,  swollen,  and  edematous. 

Blood.  During  the  acute  process,  leucocytosis  may  reach  15,000 
or  even  50,000;  later,  the  count  is  lower.  Occasionally,  especially 
in  asthenic  persons,  normal  or  subnormal  white  cell  counts  may 
be  found.    The  red  cells  and  the  hemoglobin  are  lowered  slightly. 


112  THE  LIVER 

Urine  shows  the  characteristics  of  abscess  formation  ;  sometimes 
an  increase  of  the  bile  pigments  and  a  diminished  uric  acid  relative 
to  the  urea.  When  nephritis  is  present,  the  urinary  changes  due 
to  this  condition  are  also  present. 

LARGE  SOLITARY  ABSCESS.  Hepatic  abscess  is  due  to  the  pres- 
ence of  the  amoeba  histolytica  more  frequently  than  is  perhaps  suspected.  The 
diagnosis  of  this  condition  must  rest  upon  the  history  of  the  case.  The  leuco- 
cyte count  in  the  amoebic  abscess  is  rarely  higher  than  14,000.  The  amoebae 
may  be  demonstrated  in  the  pus  if  a  warm  stage  is  used.  Vaughn  reports  one 
case  of  a  negro  man  suffering  from  an  amoebic  abscess  of  the  liver  from 
whom  eight  liters  of  pus  were  drawn  at  operation.  The  man  ultimately  made 
a  reasonably  good  recovery.  This  form  may  be  latent  and  run  a  course  without 
definite  symptoms ;  death  may  occur  suddenly  from  rupture.  When  there  are 
symptoms,  the  temperature  is  elevated  and  of  an  intermittent  or  septic  type 
and  decidedly  irregular.  There  is  profuse  sweating  particularly  when  the  patient 
is  asleep. 

Treatment.  Exploratory  aspiration  should  be  performed;  the 
region  where  the  enlargement  is  greatest  is  the  point  of  election. 
If  not  at  the  point  of  election,  the  next  best  places  are:  either  the 
lowest  interspace  in  the  anterior  axillary  line ;  or  the  seventh  inter- 
space in  the  mid-axillary  line. 

After  this,  or  when  surgery  is  contra-indicated  for  any  reason, 
the  treatment  of  the  splanchnic  and  vagus  regions,  according  to 
conditions  as  found,  gives  much  relief  and  hastens  recovery.  No 
food  or  only  limited  amounts  of  liquids  should  be  permitted.  Cool 
sponging  relieves  the  fever.  Ice  bags  over  the  liver  relieve  the 
pain. 

Prognosis.  In  traumatic  and  amoebic  abscesses  when  the  pus 
can  be  evacuated  early,  a  favorable  termination  may  be  expected. 
In  pyemic  and  other  forms,  a  fatal  result  is  to  be  expected,  though 
recovery  may  occur. 

HEPATIC  CANCER 

(Carcinoma  of  the  liver) 

Cancer  of  the  liver  is  most  common  in  late  middle  life — 35  to 
55  years.  The  primary  causes  are  heredity,  traumatism,  irritation 
from  various  causes  as  gall-stones,  and  chronic  intestinal  stasis. 
The  primary  form  is  very  rare,  and  most  common  in  men.  It  is 
nearly  always  secondary ;  this  is  most  common  in  women,  as  metas- 
tasis from  uterine  or  mammary  cancer. 

Diagnosis.  The  symptoms  are  due  to  increased  size  of  the  liver ; 
pressure  on  the  ducts  or  terminal  portal  vessels;  and  the  general 
effects  of  cancer — cachexia. 

These  symptoms  include  a  history  of  dyspepsia,  flatulence  and 
constipation.  There  are  hepatic  pain,  weight  and  fullness,  increased 
on  pressure;  increasing  emaciation;  jaundice;  ascites;  occasionally 
intense    hemorrhages;    attacks    of    local    peritonitis;    malignant 


HYDATID  CYST  113 

cachexia ;  anemia ;  and  edema  of  the  feet  and  legs.  Fever  may  be 
present  towards  the  close  of  the  disease.  In  melano-sarcoma,  pig- 
mented nodules  in  the  skin  may  be  found ;  these  are  pathogno- 
monic. Intermittent  pain  is  due  to  increased  size  of  the  organ  and 
to  inflammation  of  the  capsule. 

Hepatic  dullness  is  increased.  The  liver  is  indurated,  irregular 
in  outline,  nodulated,  sometimes  with  umbilication  of  the  nodules, 
is  painful  on  palpation,  and  the  superficial  veins  of  the  abdomen 
are  enlarged. 

The  diagnosis  is  made  by  the  physical  findings;  the  clinical 
symptoms,  and  by  the  X-ray  examination. 

Treatment.  Palliative  treatment  alone  is  indicated.  The  gentle 
springing  of  the  thoracic  spine,  relaxation  of  the  reflex  muscular 
contractions,  and  thorough  treatment  of  the  cervical  and  sub-occipi- 
tal regions,  often  give  relief.  In  the  terminal  stages  opiates  are  often 
necessary. 

Prognosis.  Death  occurs  in  three  to  fifteen  months,  rarely  two 
years,  after  the  condition  is  recognizable. 

HYDATID  CYST  OF  THE  LIVER 

(Echinococcus  of  the  liver) 

Hydatid  cyst  of  the  liver  is  due  to  invasion  and  subsequent  development 
of  the  embryos  of  the  taenia  echinococcus,  which  are  accidentally  ingested 
with  food  and  drink.  The  cysts  are  single  or  multiple,  and  most  frequently 
invade  the  right  lobe.  The  larvae  find  their  way  from  the  stomach  and  intestines 
into  the  portal  circulation  and  thus  reach  the  liver.  They  lodge  and  loose  their 
booklets,  developing  into  a  cyst.  The  cyst  wall  contains  two  layers,  the  inner 
of  which  is  the  germinal  layer  from  which  the  daughter-cysts  develop.  The 
irritation  gives  rise  to  the  outer  layer  of  connective  tissue. 

The  cyst  contains  a  clear,  non-albuminous  fluid,  of  low  specific  gravity, 
rich  in  chlorides,  containing  the  larvae,  booklets,  and  daughter-cysts.  It  grows 
slowly  and,  on  the  death  of  the  parasite,  may  undergo  inspissation  and  cal- 
cification, or  suppuration. 

Diagnosis.  Unless  the  cyst  is  large,  there  are  usually  no  symptoms.  There 
may  be  a  sense  of  fullness  in  the  hepatic  area.  Occasionally,  jaundice,  pain, 
dyspnea,  fever,  and  pyemic  symptoms  are  present.  Reflex  muscular  contrac- 
tions are  rarely  present  before  rupture  or  suppuration  occur. 

The  liver  is  painlessly,  irregularly  enlarged ;  fluctuation  may  be  detected 
in  some  cases.  If  the  cyst  is  near  the  surface,  placing  one  hand  over  the  tumor, 
and  tapping  it  lightly  with  the  fingers  of  the  other  hand  will  elicit  a  vibrating 
or  trembling  movement   (hydatid  fremitus  or  thrill). 

Aspiration  should  always  be  performed,  as  the  presence  of  a  few  booklets 
is  diagnostic. 

Suppuration  and  rupture  are  the  most  common  terminations. 

Treatment.  Incision  and  evacuation  of  the  contents  is  the  best  method. 
Aspiration  may  be  used,  but  one  is  not  certain  of  getting  all  the  infecting 
material. 

After  this  has  been  done,  the  gentle  relaxation  of  the  reflex  muscular  con- 
tractions, followed,  after  healing  of  the  surgical  wound,  by  the  correction  of 


114  THB  LIVER 

such  spinal  and  rib  lesions  as  may  be  found  on  examination,  hastens  complete 
recovery  of  health  and  lessens  the  danger  of  subsequent  hepatitis. 

Recovery  is  to  be  expected  in  uncomplicated  cases.  If  there  has  been 
infection  by  pyogenic  bacteria,  or  when  the  vitality  of  the  patient  is  low  for 
any  reason,  recovery  may  be  delayed  or  impossible. 


AMYLOID  LIVER 

(Waxy,  lardaceous,  scrofulous,  or  albuminous  liver) 

Etiology.  Among  the  causes  is  prolonged  suppuration  of  tuberculous  dis- 
ease either  of  the  bones  or  the  lungs ;  next  in  frequency  are  the  cases  asso- 
ciated with  syphilis.  It  is  seen  in  coxalgia,  rachitis,  cancer,  leukemia,  and  cer- 
tain infectious  diseases.  The  deposit  begins  in  the  arterioles  and  capillaries 
and  spreads  to  the  fibrous  tissue  and  parenchyma.    Other  viscera  are  affected. 

Diagnosis.  There  are  no  characteristic  symptoms.  Pain  is  absent.  Dis- 
orders of  digestion,  diarrhea,  emaciation,  and  anemia  are  common.  The  hepatic 
dullness  is  enormously  increased  and  there  is  prominence  of  the  liver  area. 
On  palpation,  the  liver  is  firm,  smooth  on  the  surface,  not  tender,  the  edges 
rounded  or  sharp  and  hard.  The  urine  is  increased  in  amount,  pale,  albuminous 
and  contains  amyloid  casts  when  the  kidneys  are  involved.  The  treatment  and 
prognosis  are  those  of  the  primary  disease. 

FATTY  LIVER 

Two  conditions  are  included  under  this  head :  fatty  infiltration,  or  excessive 
accumulations  of  fat-globules  in  the  hepatic  cells ;  and  fatty  degeneration,  in 
which  the  cell  protoplasm  is  partially  replaced  by  fat.  The  first  is  most  com- 
mon in  obesity  and  in  conditions  in  which  the  oxidation  processes  are  inter- 
fered with,  as  in  cancerous,  syphilitic  or  malarial  cachexia,  primary  or  severe 
secondary  anemias,  and  phthisis.  The  second  is  more  often  the  result  of  bac- 
terial or  other  toxins,  as  the  acute  infections,  alcoholism ;  poisoning  by  phos- 
phorus, chloroform,  and  other  chemicals;  and  in  combination  with  such  other 
diseases  as  cirrhosis,  amyloid  disease,  passive  congestion,  pernicious  anemia, 
chronic  dysentery,  etc.;  it  is  sometimes  found  in  pregnancy. 

Diagnosis.  Any  symptoms  present  are  due  to  the  causative  disease.  Pal- 
lor is  marked ;  the  face  may  be  swollen ;  and  the  ankles  may  be  slightly  edema- 
tous. The  liver  is  uniformly  and  sometimes  markedly  enlarged ;  is  somewhat 
soft,  regular  in  outline,  and  with  rounded  edges.  The  stools  are  pale  but  bile 
is  not  absent. 

The  urine  is  albuminous,  abundant  and  of  moderate  specific  gravity.  The 
urinary  and  blood  .changes  may  show  the  primary  disease. 

The  treatment  and  prognosis  are  those  of  the  primary  disease. 


CHAPTER  X 
DISEASES  OF  THE  GALL-BLADDER  AND  BILE  DUCTS 

CHOLANGITIS 

( Angiocholitis ;    catarrhal   jaundice;   catarrh    of   the    bile-ducts;    hepatogenous 
jaundice;  duodeno-cholangitis) 

Acute  cholangitis  is  inflammation  of  the  lower  end  of  the  com- 
mon duct,  associated  with  catarrh  of  the  stomach  and  duodenum 
and  produced  by  the  same  causes;  clinically  marked  by  jaundice. 

Etiology.  The  main  predisposing  causes  are:  excesses  in  eat- 
ing and  drinking;  exposure;  debauch;  physical  fatigue;  passive 
hepatic  congestion ;  and  certain  infectious  diseases. 

Lesions  of  the  right  lower  ribs,  and  of  the  sixth  to  the  tenth 
thoracic  vertebrae  are  usually  present.  Cervical  lesions  are  less 
constant. 

Diagnosis.  Sometimes  the  yellow  tint  of  the  skin  is  the  first 
symptom  noticed.  Often,  it  begins  with  epigastric  distress,  nausea, 
perhaps  vomiting,  looseness  of  the  bowels,  and  slight  feverishness, 
sometimes  to  101°  or  102°  F. 

In  three  to  five  days,  the  skin  and  sclera  become  yellow,  never 
bronzed ;  the  fever  disappears ;  the  skin  becomes  harsh,  dry,  and 
itchy ;  the  bowels  constipated,  the  stools  whitish  or  clay-colored 
and  accompanied  by  much  flatus  and  colicky  pains.  Jaundice  may 
be  marked,  the  skin  cold;  the  heart  action  and  respiration  slow; 
the  mind  torpid  and  greatly  depressed ;  if  much  pain  is  present, 
some  complicating  factor  should  be  suspected.  The  depression, 
discoloration,  and  bowel  condition  persist  for  one  or  two  weeks 
after  the  more  acute  symptoms  disappear.  The  liver  and  spleen 
are  slightly  enlarged. 

Tenderness  may  be  manifested  on  pressure  over  the  bile-duct 
area,  at  the  end  of  the  ninth  costal  cartilage.  The  urine  is  heavy 
and  dark,  loaded  with  urates  and  containing  bile  pigments  and  bile 
acids. 

Leucocytosis  is  moderate.  Both  red  and  white  cells  may  show 
the  eflfects  of  toxic  influences. 

Treatment.  Attention  must  be  paid  to  any  subluxations  which 
may  interfere  with  a  good  blood  supply  to  the  part  afifected.  The 
ninth  thoracic  vertebra,  the  right  tenth  rib,  and  neighboring  tis- 
sues should  receive  careful  attention. 

The  gastro-intestinal  condition  must  be  treated  according  to  the 
findings  in  each  patient. 

115 


116  THE  GALL-BLADDER  AND  DUCTS 

The  diet  should  be  carefully  regulated,  especially  as  to  quan- 
tity. Fruit  and  vegetable  juices,  diluted  with  hot  or  cold  water, 
are  good.  Irrigation  of  the  colon  with  cool  water  (80°-90°  F.) 
has  been  advised.    The  stools  must  be  carefully  watched. 

Prognosis.  If  there  are  no  complications  recovery  occurs  in 
from  two  weeks  to  several  months.  When  the  condition  persists 
longer  than  three  months,  more  serious  trouble  should  be  sus- 
pected. 

CHRONIC  CATARRHAL  CHOLANGITIS 

Chronic  catarrhal  cholangitis  may  occur  as  a  sequel  to  an  acute 
attack  of  cholangitis.  The  common  duct  may  be  completely  or 
only  partly  obstructed.  With  complete  obstruction  of  the  common 
duct  the  bile  passages  are  greatly  dilated;  there  is  usually  dilata- 
tion of  the  gall-bladder  and  of  the  ducts  within  the  liver;  the  con- 
tents of  the  ducts  and  the  gall-bladder  are  a  clear,  colorless,  usually 
sterile  mucus.  These  patients  are  the  subjects  of  chronic  jaundice 
without  fever. 

With  incomplete  obstruction  of  the  common  duct  there  is  either 
pressure  on  the  duct  or  gall-stones  in  the  common  duct  or  in  the 
ampulla  of  Vater;  the  bile  passages  are  not  much  dilated  and  the 
contents  are  bile-stained  turbid  mucus.  There  may  be  a  "ball- 
valve"  obstruction.  This  form  is  associated  with  the  so-called 
hepatic  intermittent  fever  (103°  to  105°  F.)  with  recurring  attacks 
of  chills,  fever,  and  sweating. 

The  treatment  is  practically  that  of  cholelithiasis. 

SUPPURATIVE  CHOLANGITIS* 

(Purulent  angiocholitis) 

Suppurative  cholangitis  usually  involves  the  common  duct,  and 
is  characterized  by  septic  phenomena.  The  usual  cause  is  gall- 
stones in  the  common  duct.  Cancer,  lumbricoides,  or  other  foreign 
bodies  occasionally  are  causative. 

Diagnosis.  There  is  a  history  of  attacks  of  biliary  colic,  then 
a  period  with  no  attacks,  then  later  attacks  of  temporary  jaundice, 
a  recent  one  being  followed  by  chill,  fever,  jaundice  varying  in 
intensity,  slight  or  severe  pain,  progressive  emaciation  and  loss  of 
strength.  There  may  be  nausea  and  vomiting,  or  "intermittent 
hepatic  fever."  There  is  a  smooth,  tender,  moderate  enlargement 
of  the  liver,  with  tenderness  over  the  gall-bladder  or  in  the  epigas- 
trium. 

There  is  "a  tender  area  in  the  region  of  the  twelfth  dorsal  ver- 
tebra, two  or  three  centimeters  from  the  median  line." — Boas. 

Treatment.  Surgery  is  indicated.  Cholecystectomy  with  free 
and  prolonged  drainage,  any  gall-stones  found  being  removed,  is 


CHOLECYSTITIS  117 

the  preferred  method.    The  later^  treatment  is  practically  that  of 
cholelithiasis  (q.  v.). 

Prognosis.  The  condition  is  always  grave  and  is  generally 
fatal,  unless  operation  is  early  performed.  Spontaneous  evacua- 
tion into  the  intestine  may  occur.  Rupture  into  the  peritoneum 
is  more  probable,  when  speedy  death  is  to  be  expected. 

CHOLECYSTITIS 

(Acute  infectious  cholecystitis) 

Cholecystitis  is  an  acute  inflammation  of  the  gall-bladder.  It 
may  be  catarrhal,  membranous,  suppurative,  phlegmonous,  or 
gangrenous  in  type.  The  inflammation  is  usually  due  to  bacterial 
infection  by  extension  from  neighboring  parts,  and  it  is  character- 
ized by  fever,  tenderness  and  pain  in  the  right  hypochondrium 
near  the  end  of  the  ninth  costal  cartilage. 

Etiology.  The  organisms  most  commonly  found  are  those  of 
the  colon  group,  bacillus  typhosus,  pyogenic  cocci,  and  the  pneu- 
mococcus.  Parasites  and  calculi  in  the  gall-bladder  occasionally  act 
as  causes. 

Subluxations  of  the  vertebrae  from  the  fifth  to  twelfth  dorsal 
and  the  lower  four  ribs  play  a  part  in  lowering  the  resistance  to 
pathogenic  bacteria.  Lesions  of  the  right  tenth,  eleventh  and 
twelfth  ribs  are  especially  important. 

The  gall-bladder  is  distended  and  the  cystic  duct  often  closed 
by  swelling  of  its  mucous  membrane. 

Diagnosis.  The  onset  is  abrupt  and  severe,  with  increased  tem- 
perature and  pulse  rate,  severe  paroxysmal  pain  and  extreme  ten- 
derness in  the  right  hypochondrium  at  the  ninth  costal  cartilage 
(sometimes  referred  to  some  other  location).  Vomiting  is  com- 
mon; prostration  is  usually  well  marked  or  severe;  jaundice  is 
present  or  absent;  there  may  be  obstinate  constipation.  If  pus 
forms,  the  whole  condition  becomes  septic,  and  perforation  may 
occur.  In  the  phlegmonous  form,  besides  the  usual  symptoms, 
there  is  high  temperature  with  extreme  prostration,  and  the  rapid 
development  of  the  typhoid  state.     Peritonitis  rapidly  ensues. 

A  tender  tumor  composed  of  the  gall-bladder  may  be  palpated. 
Spasm  of  the  right  rectus  muscle  is  usually  present. 

Urinary  changes  are  those  usual  in  febrile  states.  With  occlu- 
sion of  the  duct,  the  bile  pigments  and  salts  appear  in  the  urine. 

Leucocytosis  is  invariably  marked — 20,000  to  30,000. 

The  condition  may  be  confused  with  appendicitis,  congestion 
of  the  liver,  syphilis  of  the  liver,  single  or  multiple  abscesses  of 
the  liver,  pyelophlebitis,   subphrenic  abscess,  pancreatic  disease, 


118  THB  GALL-BIADDBR  AND  DUCTS 

perforation  of  gastric  or  duodenal  ulcer,  intestinal  obstruction,  and 
uremia. 

Treatment.    This  is  palliative  and  surgical. 

Correction  of  subluxations  of  whatever  character  found,  which 
result  in  lowered  tissue  resistance,  and  which  interfere  with  arterial 
and  venous  exchange  in  the  affected  part,  are  essential  factors  of 
treatment.  In  surgical  cases  this  corrective  work  should  follow 
the  healing  of  the  wound. 

The  diet  must  be  restricted  to  water  during  the  attack.  Return 
to  ordinary  food  should  be  gradual. 

Hot  applications  over  the  liver  area  lessen  the  pain. 

Prognosis.  Mild  cases  terminate  in  recovery.  Suppurative 
cases  are  unfavorable,  tending  toward  a  fatal  termination. 

Among  the  sequelae  may  be  mentioned  serous  distention  and 
empyema  of  the  gall-bladder  and  chronic  cholecystitis. 

GALL-STONES 

(Cholelithiasis;  biliary  or  hepatic  calculi;  biliary  or  hepatic  colic) 

Gall-stones  are  concretions  of  material  which  has  been  deposited 
from  the  bile;  this  is  most  often  cholesterin,  and  usually  a  nidus 
of  bacteria  or  mucin  is  present.  Gall-stones  may  be  either  single 
or  multiple. 

Etiology.  The  predisposing  causes  are  excessive  eating,  espe- 
cially of  the  carbohydrates,  tight  lacing,  sedentary  occupation, 
insufficient  exercise,  constipation,  typhoid  and  other  infections, 
enteroptosis,  and  many  other  conditions  favoring  stagnation  of  the 
bile.  Pregnancy  seems  to  have  an  influence,  as  90%  of  cases  are 
in  women  who  have  borne  children. 

Subluxations  of  the  lower  four  ribs  and  the  corresponding  ver- 
tebrae produce  conditions  which  result  in  lessened  peristalsis  and 
disturbed  circulation  and  secretion,  thus  causing  a  mild  and  chronic 
catarrh  of  the  mucosa  of  the  gall-bladder  and  the  smaller  bile  ducts. 

They  are  formed  around  a  nucleus  of  epithelral,  mucoid,  or  more  fre- 
quently, bacterial  character.  The  bacteria  are  those  of  the  colon  group,  espe- 
cially the  bacillus  coli,  and  the  bacillus  typhosus;  rarely  the  less  virulent 
of  the  pyogenic  organisms  are  thus  found. 

The  calculi  may  be  single  or  multiple.  Wherf  single,  they  are  usually  ovoid 
in  shape;  if  composed  of  pure  cholesterin,  they  are  light,  glistening,  with  a 
granulated  surface.  More  commonly,  they  are  multiple  and  faceted  from  pres- 
sure of  their  opposing  surfaces. 

In  composition,  ordinary  gall-stones  consist  chiefly  of  cholesterin  arranged 
in  laminae,  with  a  nucleus  of  bile-pigment.  They  also  contain  salts  of  calcium 
and  magnesium.  Externally,  they  may  be  yellow  or  brown  and  have  a  greasy 
surface  when  fresh.    The  number  varies  from  one  to  several  hundreds. 

Diagnosis.  Symptoms  of  chronic  catarrhal  cholec)^stitis  or 
cholangitis  often  precede  recognizable  symptoms  of  gall-stones. 


GALL-STONES  119 

These  include  constipation  and  other  gastro-intestinal  symptoms, 
uneasy  sensations  in  the  epigastrium  or  right  hypochondrium,  deep- 
seated  tenderness  over  the  gall-bladder,  sallowness  of  the  skin, 
slight  yellowing  of  the  conjunctivae.  The  scanty  urine  is  rich 
in  uric  acid  and  later  contains  bile.  If  the  stones  pass  into  the 
bowel  without  pain,  the  symptoms  disappear  temporatjly. 

Diagnosis  by  the  X-ray  is  usually  satisfactory.  Calcium  stones 
show  plainly ;  cholesterin  stones  rarely  cast  a  shadow,  but  the  evi- 
dences of  inflammation  are  evident,  so  the  diagnosis  becomes  evi- 
dent. Stereoscopic  views  give  much  clearer  definition  in  these 
cases. 

Biliary  colic  gives  rise  to  the  following  main  symptoms :  Sud- 
den and  excruciating  pain,  usually  paroxysmal,  beginning  in  the 
epigastrium  or  right  hypochondrium;  often  with  a  palpably  en- 
larged gall-bladder.  This  pain  is  due  partly  to  the  slow  progress 
in  the  cystic  duct  (when  the  stone  must  take  a  rotary  course), 
partly  to  the  acute  inflammation  accompanying  the  attack;  and 
partly  to  the  stretching  and  distention  of  the  gall-bladder  by  the 
retained  secretions. 

Shivering,  profuse  sweating,  great  feebleness  of  the  pulse,  and 
symptoms  of  collapse  are  frequent.  The  temperature  may  be  nor- 
mal or  subnormal.  Slight  fever  is  due  to  concomitant  acute 
cholecystitis. 

Reflex  vomiting  often  gives  some  relief.  Jaundice,  arising  some- 
times in  a  few  hours,  sometimes  several  days,  after  the  onset  of  the 
pain,  and  persisting  for  a  few  days  after  the  pain  is  relieved,  is  due 
to  the  stone  lodging  in  the  common  duct. 

The  attack  lasts  from  three  to  twelve  hours  but  a  rapid  succes- 
sion of  attacks  may  keep  the  patient  in  almost  continuous  pain  for 
several  days.  The  pain  ends  suddenly  when  the  stone  slips  into 
the  bowel  but  tenderness  and  prostration  continue  for  several  days. 

The  feces  should  be  examined  carefully  for  the  calculi.  Serious 
complications  may  arise  from  rupture  of  the  duct  with  fatal  peri- 
tonitis; fatal  syncope;  convulsions;  or  impacted  gall-stones. 

Impacted  Gail-Stones.  Instead  of  passing  into  the  duodenum, 
the  stone  may  remain  in  the  gall-bladder  or  be  impacted  in  the 
cystic  duct  or  the  common  duct.  If  in  the  cystic  duct  the  resulting 
dropsy  of  the  gall-bladder  can  be  felt  as  a  smooth,  movable,  ovoid 
tumor  beneath  the  ninth  costal  cartilage.  When  the  obstruction 
is  chronic,  the  contents  of  the  tumor  are  clear  mucus.  Gall-stone 
crepitus  may  be  perceived. 

Cholecystitis,  simple  or  suppurative,  may  occur,  the  latter 
(empyema  of  the  gall-bladder)  being  the  most  common.  Atrophy 
of  the  gall-bladder  may  be  a  sequel. 

If  the  stone  is  impacted  in  the  common  duct  permanent  jaun- 
dice follows;  there  is  the  persistent  or  intermittent  presence  of  bile 


120  THB  GALL-BLADDER  AND  DUCTS 

in  stool;  fever  and  enlargement  of  the  spleen.  If  the  obstruction 
is  partial  so  that  the  stone  acts  like  a  ball-valve,  the  jaundice 
varies  in  intensity,  there  are  recurrent  attacks  of  colic  with  the 
so-called  hepatic  intermittent  fever  (rigors,  pyrexia,  sweating). 
The  jaundice  deepens  with  each  attack. 

Calculus,  in  the  gall-bladder  sometimes  causes  acute  cholecys- 
titis, or  leads  to  ulceration  with  the  establishment  of  a  biliary  fistula 
opening  into  the  duodenum,  colon,  or  other  hollow  viscus,  or 
occasionally  on  the  skin.  A  large  stone  passing  through  such  an 
opening  may  cause  obstruction  of  the  bowel. 

On  examination  is  found  tenderness  and  rigidity  at  the  ninth 
costal  cartilage  which  may  extend  over  the  abdomen;  contractions 
and  hypersensitive  areas  along  the  spine  from  the  sixth  to  the 
tenth  dorsal  are  constant. 

Urine.  There  is  albumin  with  red  blood  cells.  As  soon  as  a 
stone  is  passed  the  patient  may  pass  a  large  quantity  of  clear,  pale 
urine.    When  jaundice  is  present,  bile  elements  are  found. 

Blood.  There  is  a  mild  leucocytosis  during  an  attack.  The 
coagulation  time  may  be  slow  and  should  be  tested  before  any 
operation  upon  the  gall-bladder,  or  in  the  presence  of  jaundice. 

Treatment.  "A  careful  physical  examination  from  the  point  of 
the  ninth  costal  cartilage  along  a  line  passing  through  a  point 
about  one  inch  to  the  right  of  the  umbilicus  should  be  made  with 
the  patient  lying  upon  his  back  and  with  knees  flexed  to  relax  the 
abdominal  structures.  The  fingers  of  the  operator  must  be  laid 
flat,  and  if  necessary,  the  right  hand  may  be  reinforced  by  the  left. 
The  pressure  must  be  light,  yet  firm.  If  there  should  be  any 
accumulation  whatever  in  the  duct  a  light  pressure  will  reveal  a 
tender  spot.  The  feeling  at  this  spot  will  vary  in  intensity  from  a 
dull  pain  to  a  sharp  pricking,  lancinating  sensation.  As  the  patient 
expresses:  *It  feels  as  though  you  had  a  tack  on  the  end  of  your 
fingers.'  With  careful  manipulation  along  the  course  of  the  duct 
the  concretion  is  gradually  moved  along  and  passed  through  the 
ductus  communis  choledochus  into  the  intestine  where  it  can  do 
no  more  harm." — ^Jenette  H.  Bolles. 

Preventive  measures  after  an  attack  are  most  important.  Cor- 
rection of  bony  lesions  as  found  is  the  most  essential  factor  in 
prophylaxis.  Regular  systematic  exercise,  avoidance  of  tight  belts 
and  corsets,  and  better  posture  all  are  efficient  aids. 

"If  after  a  faithful  attempt  to  cure  and  our  efforts  are  not  rewarded,  then 
many  of  these  cases  should  be  operated  and  the  gall-bladder  drained.  If  the 
attacks  of  simple  gall-bladder  disease  are  accompanied  by  high  temperature  and 
chills  which  indicate  the  presence  of  infection,  the  case  has  already  passed 
into  the  domain  of  surgery  and  should  be  operated  at  once.  Should  the  paini 
be  paroxysmal,  excruciating  and  accompanied  by  jaundice,  the  case  has  passed 
the  borderline  of  conservative  therapy  and  should  be  operated.  The  conscien- 
tious physician  avoids  the  radical  agency  of  therapy  studiously  when  he  is  in 


CANCER  121 

doubt  as  to  the  appropriateness  of  its  application  in  that  particular  case;  but 
when  he  is  convinced  it  is  the  right  thing  to  do,  he  summons  it  to  his  aid  at 
once  and  assumes  his  due  measure  of  responsibihty.  The  mere  presence  of 
gall-stones  in  the  gall-bladder  is  no  particular  indication  for  an  operation.  Sur- 
gery should  be  commanded  only  when  the  stones  give  trouble  by  inducing 
infection  or  when  manipulative  measures  do  not  enable  them  to  pass.  Fortu- 
nately f-or  the  patient  some  twenty-five  per  cent  of  the  cases  of  gall-stones  in 
the  gall-bladder  do  not  produce  any  symptoms  whatsoever." — S.  L.  Taylor. 

"To  relieve  the  pain,  inhibition  in  the  splanchnic  area,  especially  at  the 
ninth  and  tenth,  also  apply  heat  to  tlie  splanchnic  area  and  over  the  region  ol 
the  gall-bladder  to  hasten  relaxation.  Gentle  manipulations  over  the  region  of 
the  gall-bladder  and  ducts  may  help  considerably.  Of  course  you  cannot  get 
your  fingers  on  the  ducts  and  push  the  stone  through,  but  manipulations  over 
the  gall-bladder  may,  if  the  bladder  is  full  of  bile,  cause  the  stone  to  be  pushed 
into  the  duct  and  passed.  Then  give  good,  vigorous  treatment  to  the  lower 
dorsal  and  upper  lumbar  regions  for  a  few  minutes,  allow  the  patient  to  rest 
several  minutes  and  again  repeat  until  the  pain  is  reduced  by  the  stone  passing 
or  dropping  back  into  the  bladder.  The  spinal  and  abdominal  muscles  must  be 
thoroughly  relaxed." — ^J.  E.  Derek. 

The  control  of  the  diet  is  most  important.  The  patient  must 
avoid  excess  in  eating,  keeping  the  fats  and  carbohydrates  at  the 
lowest  limit  necessary  to  keep  the  body  .nourished.  Water  drink- 
ing must  be  encouraged. 

Recurrent  attacks  and  complications  which  do  not  yield  to 
treatment  may  call  for  cholecystotomy  or  cholecystectomy  as  may 
be  indicated.  The  indications  for  operation  are :  repeated  attacks 
of  biliary  colic ;  the  presence  of  a  distended  gall-bladder  with 
severe  and  resistant  attacks  of  pain  and  fever;  gall-stone  impaction 
in  the  common  duct. 

Among  the  sequelae  are  biliary  fistulse  and  obstruction  of  the 
bowels  by  gall-stones.  Malignancy  may  follow  the  repeated  irri- 
tation. 

Prognosis.  Uncomplicated  cases  terminate  in  recovery.  Ulcer- 
ation, suppuration,  or  perforation  may  be  fatal. 


CANCER  OF  THE  GALL-BLADDER  AND  OF  THE  BILE 

DUCTS 

Cancer  may  affect  either  the  gall-bladder  or  the  bile  ducts  and 
in  about  85%  of  the  cases  follows  gall-stones.  About  75%  are  in 
women.  It  may  begin  either  at  the  fundus  or  near  the  neck  of  the 
gall-bladder.  The  liver  may  be  affected  secondarily,  in  which  case 
the  progress  of  the  disease  is  rapid.  Secondary  growths  are  not 
common. 

Diagnosis.  The  pain  is  severe  and  often  paroxysmal,  with 
persistence  and  tenderness  on  pressure  in  the  intervals  between 
attacks. 

When  the  gall-bladder  is  affected,  jaundice  usually  occurs 
rather  late.    If  the  bile  ducts  are  implicated,  it  is  present  from  the 


122  THE  GALL-BLADDER  AND  DUCTS 

first  and  becomes  progressively  deeper,  the  pain  being  absent  or 
slight.  Cachexia,  progressive  emaciation,  and  profound  anemia  are 
present. 

The  tumor  is  firm,  hard,  nodular,  and  very  tender  on  pressure. 
If  the  growth  involves  the  gall-bladder,  it  extends  diagonally 
downward  and  inward  toward  the  umbilicus;  if  the  bile  ducts  are 
involved,  it  may  be  felt  as  a  smooth,  ovoid  swelling  below  the 
ninth  costal  cartilage. 

Treatment.  Is  palliative  at  best.  Surgery  may  stay  the  prog- 
ress for  a  time.  Deep,  steady  pressure  over  the  spinal  areas  of 
greatest  reflex  contraction  and  frequent  and  thorough  treatment 
of  the  cervical  tissues  may  give  great  relief.  At  the  last,  opiates 
are  often  necessary  for  the  relief  of  the  pain. 

Prognosis.  Death  is  not  as  speedy  as  in  cancer  of  the  liver,  but 
is  inevitable,  under  our  present  methods  of  diagnosis.  If  early 
diagnosis  could  be  made,  as,  for  example,  at  an  operation  for  gall- 
stones, no  doubt  early  surgical  intervention  could  give  fairly  good 
prognosis.  After  opiates  or  other  analgesic  drugs  become  neces- 
sary, these  add  complicating  discomforts  and  themselves  make  the 
prognosis  more  gloomy.  Life  may,  however,  be  prolonged  and  be 
made  endurable  by  the  use  of  these,  during  the  last  weeks  of  the 
disease. 

Prophylaxis.  Since  so  large  a  proportion  of  these  cancers  fol- 
low gall-stones,  tight  lacing,  and  rib  lesions,  the  prevention  of 
this  triad  is  important. 


CHAPTER  XI 
DISEASES  OF  THE  PANCREAS 

GENERAL  DISCUSSION 

Diseases  of  the  pancreas  are  rather  rarely  reported.  This  is 
partly  due  to  the  protected  location  of  this  gland,  and  partly 
to  the  difificulties  in  diagnosis,  when  pancreatic  disease  does  occur. 
The  pancreas  pours  its  secretion  into  the  duodenum  through  a 
rather  long  and  tortuous  duct;  infectious  agents  do  not  readily 
reach  the  gland  from  the  intestine.  Slight  variations  in  either  its 
internal  or  its  external  secretion  do  not  cause  any  recognizable 
variations  in  the  digestion  of  the  food,  nor  in  carbohydrate  metab- 
olism. The  nervous  relations  of  the  pancreas  are  practically  the 
same  as  those  of  the  liver  and  the  upper  intestinal  tract.  For  this 
reason,  reflex  muscular  contractions  and  hypersensitive  areas  do 
not  give  help  in  diagnosis.  With  more  efficient  methods  of  diag- 
nosis no  doubt  many  obscure  cases  will  be  recognized  as  due  to 
pancreatic  disease.  At  the  present  time,  no  functional  pancreatic 
diseases  are  recognized. 


HEMORRHAGE  INTO  THE  PANCREAS 

This  usually  occurs  in  individuals  over  forty  years  of  age,  but 
seemingly  bears  no  relation  to  work  or  rest.  Chronic  alcoholism 
is  a  predisposing  factor  in  some  cases. 

Diagnosis.  Slight  hemorrhages  may  cause  no  recognizable  dis- 
turbance and  only  be  found  post-mortem. 

Hemorrhage  is  characterized  by  the  sudden  onset,  usually  dur- 
ing perfect  health,  of  a  severe,  sharp  or  colicky  pain  in  the  upper 
abdomen,  accompanied  by  nausea  and  obstinate  vomiting.  The 
patient  becomes  depressed,  restless-,  and  anxious,  with  a  cold, 
sweating  skin.  The  pulse  is  small  and  rapid,  becoming  later  run- 
ning and  imperceptible.  The  temperature  is  normal  or  subnormal. 
The  abdomen  rapidly  becomes  distended  and  tender  over  its  upper 
portion.  Collapse,  syncope,  and  death  usually  supervene  within 
twenty-four  hours. 

Treatment.  Palliative  measures  are  indicated,  as  in  shock.  The 
diagnosis  becoming  apparent,  exploratory  laparotomy  may  show 
some  reparable  injury.  Without  surgical  intervention,  death  is 
inevitable  when  the  hemorrhage  is  large  enough  to  provoke  recog- 
nizable symptoms. 

123 


124  THE  PANCREAS 

ACUTE  PANCREATITIS 

Acute  pancreatitis  is  an  acute  inflammation  of  the  pancreas, 
either  hemorrhagic,  gangrenous,  or  suppurative  in  character,  affect- 
ing primarily  the  fibrous  and  fatty  interstitial  tissues,  due  to 
extension  of  disease  from  the  duodenum  or  to  traumatism,  and 
characterized  by  sudden  severe  abdominal  pain  and  vomiting,  fatty 
stools,  abdominal  distention  in  the  upper  left  quadrant,  and  rapidly 
supervening  symptoms  of  collapse. 

Etiology.  The  disease  occurs  in  overfat  males  after  forty-five 
years,  especially  those  suffering  from  gastro-intestinal  disorders, 
infectious  cholecystitis,  cholelithiasis,  and  infectious  fevers;  or 
occurs  from  traumatism,  especially  blows  in  the  middle  of  the  back. 
Alcoholism  and  chronic  mercurialism  predispose  to  the  disease. 

Diagnosis.  There  is  a  sudden  onset  with  intense  abdominal 
pain  and  tenderness  in  the  epigastrium,  nausea,  and  vomiting  with 
severe  retching.  Premonitory  pain  around  the  gall-bladder  has 
been  reported.  The  upper  left  quadrant  of  the  abdomen  becomes 
distended  and  tympanitic.  The  temperature  is  subnormal  at  first, 
later  moderate  fever  may  be  ushered  in  with  a  chill.  Constipation, 
dyspnea,  jaundice,  delirium  and  hiccough  with  symptoms  of  col- 
lapse rapidly  follow.  The  patient  succumbs,  as  a  rule,  within  four 
days. 

If  there  are  chills,  fever,  marked  abdominal  distention,  tender- 
ness, and  tympany  with  jaundice,  collapse  following  the  pain  or 
vomiting,  it  indicates  a  termination  by  gangrene. 

If  there  are  irregular  fever,  irregular  vomiting,  jaundice,  and 
constipation,  the  indications  are  that  suppuration  is  in  progress 
and  will  terminate  by  death  within  one  to  four  weeks;  or  by 
becoming  chronic,  the  course  lasting  several  months  or  a  year. 

The  spine  may  show  muscular  contractions  and  subluxations 
along  the  lower  dorsal  and  upper  lumbar  region.  The  upper  left 
quadrant  of  the  abdomen  is  distended  and  tympanitic ;  tender 
points  due  to  fat  necrosis  may  be  found  scattered  over  the  abdo- 
men. 

The  fat-splitting  ferment  may  be  found  in  the  urine,  and  the 
ethereal  sulphates  are  reduced.  Albuminuria  is  frequent.  The 
feces  contain  much  fat. 

The  condition  is  difficult  to  distinguish  from  intestinal  obstruc- 
tion, perforation  of  the  stomach,  acute  toxic  gastritis,  and  biliary 
colic. 

Treatment.  Palliation  of  the  symptoms  is  all  that  can  be  done 
in  most  cases.    Exploratory  laparotomy  is  sometimes  indicated. 

Prognosis.  Death  usually  occurs  in  from  two  days  to  four 
weeks.  * 


CHRONIC  PANCREATITIS  125 

CHRONIC  PANCREATITIS 

Chronic  pancreatitis  is  a  condition  of  interstitial  overgrowth 
producing  increased  size  and  density,  compression  of  the  secreting 
structure,  pigmentary  deposits,  and  calculi  in  the  ducts,  and 
marked  clinically  by  fatty  stools,  jaundice,  dyspepsia,  and  loss  of 
weight. 

Etiology.  Arteriosclerosis,  alcoholism,  and  syphilis  are  predis- 
posing causes.  Among  the  exciting  factors  may  be  mentioned 
obstruction  of  the  pancreatic  duct,  extension  of  disease  from 
chronic  gastro-duodenitis  or  catarrh  of  the  bile  passages,  and  dia- 
betes. Lesions  of  the  eighth  to  the  tenth  vertebrae  and  ribs  modify 
the  circulation  of  the  pancreas. 

The  anatomic  changes  are  of  two  forms,  interlobular  and  inter- 
acinar.  The  latter  invades  the  islands  of  Langerhans.  Cysts  and 
calculi  may  be  formed  in  the  ducts. 

Diagnosis.  The- main  symptoms  are  paroxysmal  pain,  abdom- 
inal distention,  indigestion,  loss  of  weight,  diarrhea  with  fatty 
stools,  irregular  fever,  and  jaundice. 

The  distended  abdomen  may  be  found  tender  in  the  upper 
part.  There  may  be  albuminuria,  glycosuria  in  various  combina- 
tions, and  the  ethereal  sulphates  in  the  urine  are  reduced. 

The  stools  contain  much  fat,  are  often  clay-colored,  and  have 
a  large  muscle  fiber  content  when  meat  is  eaten.  The  X-ray  may 
help  in  diagnosis  by  excluding  certain  gastro-intestinal  diseases. 

Treatment.  If  calculi  or  gall-stones  are  the  cause,  operation  is 
indicated.  Alcoholic,  syphilitic  and  arterio-sclerotic  cases  should 
receive  suitable  treatment  for  these  conditions.  In  all  cases,  treat- 
ment for  the  correction  of  the  bony  lesions  as  found,  is  indicated. 

Prognosis.  The  course  of  the  disease  is  very  slow.  The  appear- 
ance of  glycosuria  makes  the  outlook  grave. 

PANCREATIC  CYSTS 

Pancreatic  cysts  are  usually  retention  cysts,  due  to  closure  of  duct  of 
Wirsung  by  concretions,  tumors,  or  cicatrices,  and  may  result  from  the  encap- 
sulation of  extravasated  blood,  echinococcus  disease,  malignant  tumors,  or  may 
be  congenital. 

Trauma  and  inflammation  are  important  factors  of  etiology. 

Diagnosis.  The  main  symptom  is  progressive  enlargement  of  the  left 
portion  of  the  epigastrium  between  the  costal  cartilages  and  the  median  line. 
The  general  symptoms  of  abdominal  pain,  digestive  disturbances,  emaciation, 
constipation,  recurring  intestinal  hemorrhages,  with  pressure  symptoms  of 
jaundice,  ascites,  or  dyspnea,  occur  only  when  the  tumor  is  of  some  considerable 
size  and  are  dependent  upon  the  location  to  a  considerable  degree. 

The  complexion  is  peculiar.    The  skin  has  a  dirty  yellowish  or  earthy  hue. 

Inflation  of  the  stomach  and  colon  shows  that  the  tumor  lies  behind  them. 
It  is  found  to  be  globular,  resisting,  inelastic,  nonfluctuant,  dull  to  percussion, 
and  may  displace  other  organs  and  structures. 


126  THE  PANCREAS 

On  aspiration,  the  fluid  found  is  reddish  or  dark  brown  color;  contains 
blood  or  blood  coloring  matters;  cell  detritus;  fat  granules;  and  sometimes 
cholesterin ;  its  consistency  is  usually  mucoid,  rarely  thin ;  of  alkaline  reaction ; 
specific  gravity  is  1010  to  1020;  the  pancreatic  ferments  are  present  in  variable 
number  and  proportions.  The  most  important  test  to  be  made  is  for  the  diges- 
tion of  fibrin  and  albumin. 

Glycosuria  and  albuminuria  are  usually  present.  Feces  contain  considerable 
fat. 

Treatment.  After  the  withdrawal  of_the  characteristic  fluid  by  aspiration, 
exploratory  incision  is  indicated.  Recovery  is  to  be  expected  in  the  absence 
of  complications. 

CANCER  OF  THE  PANCREAS 

Cancer  of  the  pancreas  occurs  as  a  primary  form,  usually  of 
the  scirrhous  variety,  affecting  first  the  head  of  the  pancreas,  and 
is  characterized  clinically  by  dull  epigastric  pain,  intense,  persistent 
jaundice,  tumor  formation,  clay-colored,  greasy  stools,  various 
pressure  symptoms,  and  very  rapid  v^asting  and  cachexia.  Sec- 
ondary cancer  is  more  rare. 

Etiology.  Men  are  more  often  affected ;  the  disease  is  most  apt 
to  appear  after  the  age  of  forty. 

Diagnosis,  The  symptoms  are  suggestive;  other  methods  of 
examination  are  very  unsatisfactory.  X-ray  sometimes  helps  in 
the  diagnosis.  The  symptoms  include:  obstinate  chronic  or  recur- 
ring gastritis,  with  atypical  symptoms  and  gastric  findings;  pro- 
gressive cachexia ;  dull,  obstinate  epigastric  pain ;  sometimes 
nocturnal  paroxysms  of  extremely  severe  pain,  with  vomiting 
and  diarrhea,  sometimes  associated  with  intercurrent  constipation. 
Intense  and  persistent  jaundice  may  be  due  to  pressure  upon  the 
bile  duct.  Pressure  upon  the  portal  vein  may  be  responsible  for 
ascites ;  pressure  upon  the  thoracic  duct  may  cause  chylous  ascites 
and  chyluria;  this  may  simulate  certain  tropical  diseases.  Pres- 
sure upon  the  vena  cava  may  cause  edema  of  the  legs  and  abdomen. 
Pressure  upon  the  duodenum  may  cause  signs  of  acute  intestinal 
obstruction;  less  degree  of  pressure  may  cause  gastrectasis. 
Aortic  pulsation  is  readily  transmitted. 

The  stools  are  apt  to  be  greasy  and  clay-colored.  Undigested 
meat  may  be  found  in  the  nondiarrheic  stools.  Various  tests  for 
the  ef^ciency  of  the  pancreas  have  been  described ;  these  are  based 
upon  the  relative  digestibility  of  different  food  materials  by  the 
digestive  juices.  Glycosuria  may  be  present.  Other  urinary  and 
blood  findings  are  about  as  in  cancer  elsewhere  in  the  body.  In 
emaciated  patients  the  tumor  may  be  felt. 

Metastasis  to  the  liver  and  spleen  are  frequent ;  to  other  organs, 
occasionally. 

Treatment.  Only  palliative  treatment  is  possible.  Relaxation 
of  the  reflex  muscular  contractions,  with  or  without  correction  of 


CANCER  127 

the  bony  lesions,  gives  relief,  and  prolongs  comfo'rtable  existence 
to  a  certain  extent.  These  cancers  are  inoperable  by  the  time  the 
diagnosis  is  possible. 

Prognosis.  Very  rarely  early  diagnosis  and  removal  of  the 
cancer  are  possible ;  life  may  be  prolonged  even  though  recur- 
rences are  to  be  expected.  When^the  metastases  in  the  liver  give 
the  first  recognizable  symptoms,  as  is  often  the  case,  death  is  not 
long  delayed.  Palliative  measures  are  usually  even  more  inefhcient 
in  these  cases  than  in  other  cancers  of  the  upper  abdominal  region. 

PANCREATIC  CALCULI 

(Pancreatic  lithiasis) 

Pancreatic  calculi  are  multiple,  pea-sized,  inspissated  particles  of  altered 
pancreatic  secretion  around  which  concretions  of  calcium  carbonate  and  phos- 
phate have  been  laid  and  are  found  in  the  pancreatic  duct,  and  its  branches. 
Inflammations  of  the  gland,  or  influences  which  caused  altered  secretions,  are 
factors  of  etiology. 

They  are  often  unattended  by  symptoms  being  found  only  at  autopsy.  When 
symptoms  arise,  usually  resulting  from  closure  of  the  ducts,  or  passage  of  the 
stones,  the  condition  resembles  biliary  colic.  Glycosuria,  fatty  stools,  and  the 
passage  of  the  calculi  by  bowel  may  lead  to  correct  diagnosis.  X-ray  examina- 
tion is  usually  decisive. 

The  methods  given  for  biliary  colic  are  to  be  used  during  the  passage  of 
stones.    Surgical  removal  may  be  indicated  after  careful  study  of  X-ray  plates. 


CHAPTER  XII 
DISEASES  OF  THE  PERITONEUM 

GENERAL  DISCUSSION 

The  peritoneum  is  subject  to  diseases  which  originate  else- 
where— as  in  perforation,  extension  of  inflammation,  metastases  of 
malignant  growths,  and  other  conditions  of  similar  nature.  The 
visceral  layer  of  peritoneum  is  almost  or  quite  devoid  of  sensory 
nerves;  the  parietal  layer  is  plentifully  supplied  with  sensory 
nerves.  This  accounts  for  the  observed  fact  that  inflammatory 
processes  limited  to  the  visceral  layer  cause  little  or  no  pain,  and 
usually  no  recognizable  reflex  muscular  contractions,  whereas  com- 
paratively slight  involvement  of  the  parietal  layer  causes  severe 
pain  and  marked  reflex  muscular  contractions  in  the  lower  thoracic 
and  lumbar  spinal  muscles,  as  well  as  in  the  abdominal  muscles. 
It  must  not  be  forgotten  that  the  intestinal  tract  is  fairly  well 
supplied  with  sensory  nerves,  and  that  intestinal  inflammations 
do  produce  pain  and  reflex  contractions. 

The  vasomotor  nerves  of  the  peritoneum  have  not  been  well 
studied.  The  blood  supply  to  the  peritoneum  itself  is  not  espe- 
cially abundant,  though  many  large  vessels  pass  through  its  folds. 
The  endothelial  layer  of  cells  acts  as  a  secretory  membrane,  and 
the  factors  which  modify  this  secretion  have  not  yet  been  well 
studied.  Variations  in  this  secretion  seem  to  be  due  to  variations 
in  the  circulation,  yet  circulatory  phenomena  do  not  seem  to 
account  for  all  the  variations  in  the  formation  of  the  peritoneal 
fluid. 

ASCITES 

(Peritoneal  dropsy;  hydroperitoneum) 

Ascites  or  dropsy  of  the  peritoneum  is  a  symptom  of  some 
condition  which  causes  an  increased  transudation  of  fluid  into 
the  peritoneal  cavity.  It  is  characterized  by  a  distended  abdomen, 
fluctuation,  dullness  on  percussion,  displacement  of  organs  and 
dyspnea,  plus  the  symptoms  of  its  cause. 

Etiology.  Local  causes  are:  Portal  obstruction,  either  within 
or  outside  of  the  liver,  as  cirrhosis  and  congestion ;  neoplasms  of 
the  liver  and  pancreas;  thrombosis  of  the  portal  vein;  chronic 
peritonitis,  simple,  malignant,  or  tuberculous.  It  may  be  second- 
ary to  malignant  disease  in  connection  with  the  intestine  and 
other  abdominal  organs.  Among  the  general  causes  are  renal, 
cardiac,  or  respiratory  disease  or  anemia.  ^ 

128 


ACUTE  PERITONITIS  129 

Diagnosis.  Enlargement  of  the  abdomen  is  most  marked  in  the 
flanks  when  the  patient  is  lying  on  his  back ;  the  skin  is  tense  and 
shiny  with  dilated  superficial  veins  on  the  surface.  The  umbilicus 
is  prominent.  Fluctuation  and  a  thrill  transmitted  to  the  exam- 
ining hand  laid  flat  upon  one  flank  when  the  opposite  flank  is 
tapped  by  the  finger  are  characteristic.  Percussion  yields  a  dull 
note  which  alters  when  the  patient  changes  position. 

The  general  symptoms  include  constipation,  scanty  urination, 
and  embarrassed  respiration  and  cardiac  action. 

In  noninflammatory  cases  the  ascitic  fluid  is  light  yellow  or 
straw-colored;  specific  gravity,  1010  to  1015,  contains  albumin, 
2.5  per  cent  or  less.  In  peritonitis,  the  fluid  has  a  specific  gravity 
of  1018  or  more  and  4.5  per  cent  and  over  of  albumin. 

In  chylous  ascites,  the  fluid  is  turbid  and  milky,  exhibiting  oil 
globules'  In  malignant  ascites,  it  is  often  dark  from  blood,  and 
cancer  cells  may  be  found  under  the  microscope.  The  fluid  in 
tuberculosis  may  also  be  hemorrhagic. 

Treatment.  The  main  treatment  is  that  of  the  primary  disease. 
Osteopathic  work  in  the  lower  dorsal  and  lumbar  regions  is 
urgently  indicated.  Improve  the  general  health  by  all  means  at 
command. 

The  bowels  and  kidneys  must  be  kept  active  by  the  usual 
methods.     Sweating  may  relieve  the  condition. 

A  dry  diet  is  best.  The  amount  of  fluids  taken  into  the  body 
is  to  be  carefully  determined  for  each  patient. 

If  the  symptoms  of  pressure  or  dyspnea  are  at  all  severe,  the, 
fluid  may.  be  evacuated  by  Southey's  tubes  or  by  aspiration. 
Paracentesis  may  be  repeated  many  times,  if  asepsis  is  observed. 
The  abdomen  must  be  supported  by  bandages,  gradually  tightened 
during  the  removal  of  the  fluid,  as  its  sudden  removal  causes  the 
vessels  to  become  engorged  with  blood. 

Prognosis.  If  the  ascites  is  due  to  organic  disease  the  prospect 
is  unfavorable.  In  peritoneal  cases  the  outlook  is  more  favorable. 
In  the  rare  idiopathic  cases  recovery  is  the  rule  within  a  few  weeks. 


ACUTE  PERITONITIS 

(Inflammation  of  the  peritoneum) 

Acute  peritonitis  is  an  acute  inflammation  of  the  peritoneum. 
It  is  rarely  primary,  usually  secondary  to  pathological  changes  of 
the  abdominal,  pelvic,  or  thoracic  viscera. 

Etiology.  The  main  causes  of  peritonitis  are  bacterial  infec- 
tion; extension  of  inflammation  from  neighboring  organs,  espe- 
cially the  pelvic  organs ;  strangulations  of  the  bowel ;  penetrating 
wounds;   severe  injuries   to  the   dorsal  or  lumbar  spine  and  to 


130  THE  PERITONEUM 

the  lower  three  or  four  ribs;  cold  and  exposure;  and  those  cases 
occurring  secondary  to  perforation  of  an  abdominal  viscus.  Almost 
any  of  the  pathogenic  organisms  may  be  involved.  Bacillus  coli 
communis,  tubercle  bacillus,  gonococcus,  pneumococcus,  bacillus 
typhosis,  anthrax,  and  the  streptococcus,  staphylococcus  and  indeed 
any  pyogenic  bacteria  may  be  found,  either  alone  or  in  various 
combinations.    Amebic  infection  may  occur. 

Pathology.  The  typical  changes  are:  Hyperemia  with  loss  of  luster, 
most  marked  where  the  intestinal  coils  are  not  in  close  contact  with  one  another ; 
followed  by  fibrinous  exudation,  giving  a  more  or  less  shaggy  appearance;  effu- 
sion of  fluid  which  may  be  highly  fibrinous  and  coagulate  easily,  forming  exten- 
sive adhesions  or  may  become  purulent. 

Acute  Localized  Peritonitis  may  be  appendicular  or  pelvic,  orig- 
inating in  the  Fallopian  tubes  or  uterus,  or  may  implicate  the  cavity  of 
the  lesser  peritoneum  (subphrenic  peritonitis).  Pulmonary  or  pleuritic  abscess 
may  penetrate  the  diaphragm.  It  may  follow  direct  injury,  but  usually  is  due 
to  disease  of  some  abdominal  organ,  most  commonly  resulting  from  perfora- 
tion of  a  gastric  ulcer.  Local  signs  are  usually  associated  with  hectic  fever, 
sweating,  rigors,  and  emaciation. 

Diagnosis.  The  symptoms  of  acute  general  peritonitis  are 
most  characteristic.  Great  pain  and  tenderness  over  the  abdomen 
is  constant;  the  tenderness  may  be  so  marked  that  the  slightest 
touch  causes  exquisite  agony.  The  abdomen  is  tense,  rigid  and 
tympanitic.  Respiration  is  shallow  and  thoracic,  30  to  40  per 
minute.  Pulse  is  wiry  and  incompressible,  100  to  150  per  minute. 
The  temperature  is  usually  101°  to  103°  F.,  rarely  rising  suddenly 
to  higher  points.  Rarely  a  subnormal  temperature  is  found.  The 
face  is  pale,  pinched,  and  anxious  in  expression.  Constipation  is 
common;  rarely  there  are  diarrheal  attacks.  There  is  persistent 
vomiting  of  greenish  fluid  after  the  stomach  contents  and  the  con- 
tents of  the  duodenum  have  been  passed.  Hiccoughs  may  be  very 
annoying.  The  tongue  is  usually  small  and  red.  Moderate  uni- 
form abdominal  distention;  increased  resistance,  absence  of  visible 
peristalsis,  and  later,  dullness  in  the  flanks  from  fluid  effusion  are 
constant. 

In  perforative  peritonitis,  the  abdomen  may  be  tympanitic  all 
over,  the  hepatic  and  splenic  flexures  being  completely  obliterated. 
Partial  obliteration  of  the  hepatic  dullness  may  be  due  to  meteor- 
ism.  Spasm  of  the  muscle  overlying  the  primary  inflammatory 
focus  is  a  valuable  indication  of  the  source  of  infection. 

The  muscles  of  the  dorsal  and  lumbar  regions  are  found  to  be 
tensely  contracted.  Various  subluxations  may  be  found ;  these  are 
probably  accidental  or  secondary. 

The  urine  is  scanty,  highly  colored,  containing  an  excess  of 
indican. 

Treatment.  Absolute  rest  and  good  nursing  are  essential. 
Deep,  steady  pressure  in  the  dorsal  and  lumbar  spinal  regions  will 
relieve  some  of  the  pain.     Relaxation  of  the  spinal  and  cervical 


SUBPHRENIC  PERITONITIS  131 

muscles  will  lessen  the  amount  of  reflex  irritation.     The  bowels 
must  be  cleaned  out  and  kept  active. 

To  further  alleviate  the  pain,  local  applications  of  either  heat 
or  cold  may  be  used.  With  much  shock  or  collapse,  an  intravenous 
or  subcutaneous  injection  of  normal  saline  may  be  used  with  good 
result. 

"Gastric  lavage  should  be  used  to  control  vomiting;  no  food  or  water  is 
to  be  given  by  mouth  until  the  acute  condition  is  mitigated.  Proctoclysis  should 
be  continued  in  severe  cases,  intermittent  in  milder  ones.  In  the  presence  of 
septic  material  in  the  peritoneal  cavity,  surgery  is  imperative.  Nutrient  enemas 
may  be  employed." — C.  A.  Champlain. 

Diet.  If  there  is  much  vomiting,  ice  may  be  given.  Either  an 
absolute  fast,  in  well-nourished  patients  or  peptonized  milk,  light 
gruels,  albumen  water,  or  beef  juice  in  very  small  amounts  for 
asthenic  cases,  is  advisable. 

If  there  is  reason  to  suspect  perforation,  strangulation,  or 
other  operable  disease,  speedy  surgery  is  indicated.  Exploratory 
laparotomy  is  often  justifiable. 

The  prognosis  depends  on  the  cause;  perforation  may  be  fatal 
within  a  few  hours,  the  prospect  of  recovery  is  in  reverse  ratio 
to  the  amount  of  delay  in  operating;  septic  cases  are  usually  fatal 
within  a  week ;  if  the  process  is  localized,  the  outlook  is  more 
favorable. 

SUBPHRENIC  PERITONITIS 

Subphrenic  peritonitis  is  inflammation  of  the  peritoneum  cov- 
ering the  right  and  left  lobes  of  the  liver,  or  the  lesser  cavity  of 
the  peritoneum,  together  with  that  of  the  adjacent  portions  of  the 
diaphragm.    It  is  usually  suppurative. 

Etiology.  The  main  causes  are :  Perforation  of  a  gastric  ulcer ; 
upward  extension  of  appendicitis;  perforation  of  the  duodenal 
ulcer;  extension  of  pneumonic  infection;  perforation  of  an 
empyema  through  the  diaphragm;  malignant  disease  of  the  stom- 
ach and  liver;  rupture  of  hepatic,  perinephritic,  or  pancreatic 
abscess;  diseases  of  the  gall-bladder;  traumxa. 

Diagnosis.  The  onset  is  abrupt,  especially  if  due  to  perforation 
of  an  ulcer,  with  severe  epigastric  or  hypochondriac  pain  and  ten- 
derness, vomiting  of  bile-stained,  sometimes  bloody  fluid ;  rapid, 
embarrassed  or  painful  respiration.  Soon  after,  indications  of 
sepsis  supervene.  Later,  the  abscess  may  perforate  into  the  pleural 
cavity  through  the  diaphragm,  and  establish  a  communication  with 
the  bronchus  producing  a  severe,  paroxysmal  cough  and  profuse 
purulent  expectoration. 

The  physical  signs  are  often  extremely  perplexing.  When  on 
the  right  side,  there  may  be  visible  bulging,  deficient  motility  in 
the  right  hypochondrium,  the  liver  beirtg  pushed  downward,  and 


132  THE  PERITONEUM 

with  an  apparent  vertical  and  upward  increase  of  heptatic  dullness 
to,  perhaps,  the  fourth  rib.  If  the  abscess  contains  air,  there  will 
be  a  tympanitic  zone  between  the  liver  dullness  and  the  pulmonic 
resonance.  Change  of  position  of  the  patient  alters  the  line  of 
dullness.     Succussion  sounds  may  be  elicited. 

When  the  abscess  is  in  the  lesser  peritoneal  cavity  the  signs 
are  found  upon  the  left  side.  If  it  contains  a  large  quantity  of 
pus,  a  tumor  may  be  found  in  the  left  hypochondrium,  epigastrium, 
or  the  umbilical  region.  The  colon  invariably  lies  below  the  tumor 
and  never  in  front  of  or  above  it. 

The  diagnosis  is  made  mainly  by  the  physical  signs,  coupled 
with  the  history.  The  earliest  symptom  is  upper  abdominal  pain 
of  severe  character,  and  vomiting. 

In  suspected  cases,  aspiration  should  be  done  in  the  seventh 
or  eighth  interspace  in  the  midaxillary  line. 

If  the  fluid  flows  more  freely  during  inspiration,  the  indications 
are  that  it  is  the  subphrenic  abscess,  because  the  intra-abdominal 
pressure  is  increased  during  inspiration. 

Treatment.  Prompt  drainage,  followed  by  rest  and  the  treat- 
ment for  local  peritonitis  should  give  fair  prognosis  for  recovery. 

CHRONIC  PERITONITIS 

Chronic  peritonitis  is  a  chronic  inflammation  of  the  peritoneum. 
It  may  be  simple,  tuberculous,  or  malignant,  producing  changes  in 
the  thickness  of  the  peritoneum,  shortening  of  the  mesentery  and 
omentum,  diminishing  the  caliber  of  the  bowel  and  producing 
many  adhesions.    It  may  be  local  or  general. 

Chronic  Local  Peritonitis  most  commonly  affects  the  capsule 
of  the  liver  or  spleen  (perihepatitis  or  perisplenitis)  where  it  may 
sometimes  be  recognized  by  a  rubbing  sound  upon  auscultation. 
It  less  commonly  affects  the  intestinal  peritoneum,  appendix,  and 
the  pelvic  organs.  In  either  case,  it  causes  adhesions  which,  in 
connection  with  the  intestine,  may  form  bands  which  lead  to 
obstruction  or  give  rise  to  more  or  less  constant  and  severe  colicky 
pain. 

Chronic  Diffuse  Peritonitis  is  associated  with  cirrhosis  of  the 
liver,  chronic  Bright's  disease,  chronic  alcoholism,  and  syphilis. 
It  sometimes  follows  an  acute  attack,  and  may  form  a  part  of  a 
general  serositis  in  which  the  pleurae  and  the  pericardium  also 
suffer. 

Pathology.  The  peritoneum  is  greatly  thickened;  the  mesentery  and 
omentum  are  shortened;  the  caliber  of  the  bowel  is  diminished;  there  are  numer- 
ous adhesions ;  and  effusion  may  be  moderate  in  amount,  the  fluid  being  divided 
by  adhesions  into  separate  compartments ;  or  it  may  be  extensive,  the  fluid  being 
free  in  the  abdominal  cavity. 


CANCER  133 

Diagnosis.  The  symptoms  are  often  obscure  and  indefinite. 
There  may  be  vague  abdominal  discomfort,  burning  sensations, 
colicky  pains,  and  either  constipation  or  diarrhea.  There  may  be 
a  slight,  irregular  fever.  Loss  of  flesh  and  strength  are  noticeable 
and  there  is  more  or  less  ascites  or  one  or  more  collections  of 
fluid.  There  may  be  some  abdominal  distention.  The  omentum 
may  be  rolled  and  puckered  into  a  transverse  cylindrical  mass 
between  the  stomach  and  the  colon. 

Treatment.  Removal  of  the  cause,  if  possible,  is  the  first  con- 
sideration. Then,  attention  to  the  general  health,  strengthening 
the  resistance  by  stimulation  of  the  liver,  and  correction  of  the 
subluxations  found  in  each  patient.  The  nutritional  areas  need 
special  attention. 

If  there  is  much  fluid,  which  persists,  then  repeated  tappings 
are  called  for. 

Very  slow  and  gentle  abdominal  manipulations  are  helpful. 
Any  structural  conditions  which  interfere  with  the  circulation 
should  be  corrected.  Carefully  graded  exercises,  especially  those 
which  include  "hand  and  foot"  walking,  give  excellent  results. 
These  factors  are  to  be  avoided  during  an  acute  attack  or  an 
exacerbation  of  a  chronic  process. 


CANCER  OF  THE  PERITONEUM 

(Malignant  peritonitis) 

Cancer  of  the  peritoneum  is  nearly  always  secondary  to  cancer 
of  the  stomach,  liver,  or  pelvic  organs. 

-  The  peritoneal  surface  is  studded  with  cancerous  nodules  which 
tend  to  cause  it  to  pucker;  the  intestine  may  be  narrowed. 

Diagnosis.  The  most  frequent  symptom  is  chronic  ascites  with 
progressive  emaciation.  On  palpation  the  tender  nodules  may  be 
felt  through  the  wasted  abdominal  walls.  Secondary  nodules  and 
indurated  masses  are  common  about  the  umbilicus.  There  may  be 
enlarged  inguinal  glands.  The  aspirated  fluid  is  usually  hem- 
orrhagic and  contains  the  cell  groups  of  Foulis.  Carcinoma  occurs 
usually  after  middle  life,  with  marked  cachexia  and  induration 
around  the  umbilicus. 

Treatment.  Only  palliative  treatment  is  possible.  These  cases 
are  inoperable  in  practically  every  instance  in  which  diagnosis  is 
possible. 

Opiates  may  become  necessary  before  death ;  their  use  should 
not  be  begun  too  early,  nor  should  suffering  be  permitted  when 
the  hopelessness  of  the  condition  is  recognized. 


PART  II 
DISEASES  OF  THE  CIRCULATORY  SYSTEM 


GENERAL  DISCUSSION 

The  heart  is  subject  to  the  effects  produced  upon  the  circula- 
tion of  the  blood  both  through  variations  in  its  nervous  control 
and  through  variations  in  the  resistance  offered  to  the  expelling 
force  of  the  systole.  The  manner  in  which  the  nervous  mechanism 
may  be  deranged  is  best  understood  by  reference  to  physiological 
relationships  of  the  cardiac  nerve  centers. 

The  vagus  nerve  carries  inhibitory  impulses  to  the  cardiac 
ganglia.  .It  carries  sensory  fibers  which  may  reflexly  affect  the 
heart's  action,  and  also  the  tension  of  the  blood  vessels  over  the 
body,  especially  of  the  splanchnic  region. 

The  white  rami  of  the  upper  thoracic  region  carry  impulses 
which  increase  the  speed  and  the  force  of  the  heart's  beat  to  the 
superior  and  the  middle  cervical  sympathetic  ganglia.  The  gray 
fibers  from  these  ganglia  join  the  vagi  and  are  carried  with  them 
to  the  heart,  where  they  are  distributed  to  the  muscle  fibers.  The 
same  pathway  which  carries  the  augmentor  and  accelerator 
impulses  to  the  heart  carries  also,  probably,  impulses  which  influ- 
ence the  size  of  the  cardiac  blood  vessels.  This  matter  is  not 
proved.  Also,  viscero-sensory  nerves  are  carried  from  the  heart, 
upward  with  the  vagi,  and  thence  in  the  path  of  the  cardiac  accel- 
erators, to  the  heart  center  in  the  upper  thoracic  segments. 

Both  the  vagus  center  and  the  upper  thoracic  centers  are  con- 
trolled by  a  general  heart  center  in  the  medulla,  which  may  or 
may  not  be  identical  with  the  vagus  center. 

The  heart  may  be  diseased  by  the  following  conditions :  abnor- 
mal pressure  in  the  blood  vessels ;  poisonous  substances  in  the 
blood  stream  and  starvation  through  poor  blood ;  local  infection ; 
abnormal  positions  of  the  first  to  the  fifth  thoracic  vertebrae  and 
ribs;  and  muscular  tension  in  the  cervical  region,  of  such  a  nature 
as  to  press  the  pulsating  carotid  more  closely  against  the  vagus 
fibers;  abnormal  sensory  impulses  carried  to  the  centers  from 
other  parts  of  the  body,  usually  viscera  innervated  by  the  vagus. 

The  diagnosis  of  many  obscure  cardiac  conditions  is  often  very 
much  facilitated  by  the  aid  of  the  Roentgen  ray.  Relative  increases 
in  size,  shape,  and  density  are  shown  positively.  Abnormalities  of 
position  and  sometimes  the  adhesions  causing  them  can  be  deter- 
mined in  no  other  way  as  accurately.  Stereoscopic  radiographs 
are  especially  valuable  in  conjunction  with  the  fluoroscopic  exam- 
ination. 134 


CHAPTER  XIII 
DISEASES  OF  THE  PERICARDIUM 

ACUTE  PERICARDITIS 

(Acute  plastic  or  dry  pericarditis;  acute  fibrinous  pericarditis) 
Acute  pericarditis  is  an  inflammation  of  one  or  both  layers  of 
the  outer  covering  of  the  heart. 

Etiology.  The  exciting  causes  are  rheumatism  and  gout,  erup- 
tive fevers;  pneumonia;  septicemia  and  pyemia  from  whatever 
cause ;  tuberculosis,  nephritis,  and  extension  of  disease  processes 
from  neighboring  parts. 

Subluxations  of  the  fourth  and  fifth  thoracic  vertebrae,  the  first 
to  fifth  ribs,  the  clavicles,  the  atlas  and  axis,  are  found  very  con- 
stantly in  pericarditis.  The  reflex  muscular  contractions  involve 
most  constantly  the  third,  fourth  and  fifth  thoracic  and  the  upper 
cervical  segments.  The  lesions  mentioned  must  be  considered 
important  etiological  factors. 

Pathology.  In  fibrinous  pericarditis,  the  usual  form,  there  is  hyperemia 
with  loss  of  luster.  The  exudation  of  fibrin  gives  the  pericardial  surfaces  a 
peculiar  shaggy  or  "bread  and  butter"  appearance.  The  process  often  stops  at 
this  stage,  constituting  the  plastic  form.  In  pericarditis  with  effusion,  the 
serous  or  sero-fibrinous  fluid  may  amount  to  two  litres.  This  type  is  most  fre- 
quently associated  with  acute  rheumatism,  tonsillitis,  tuberculosis,  and  septicemia. 
The  absorption  of  the  exudate  may  result  in  slight  or  extensive  adhesions  which 
may  permanently  hinder  the  cardiac  action. 

Suppurative  pericarditis  is  due  to  pyogenic  infection  as  in  pyemic  or  local 
processes  and  the  fluid  is  generally  purulent  from  the  beginning.  Hemorrhagic 
effusion  is  generally  due  to  tuberculosis  or  malignant  disease.  In  nearly  all 
cases  the  myocardium  shares  in  the  inflammation. 

Diagnosis  is  difficult,  especially  in  fat  people.  The  subjective 
symptoms  are  often  obscure  and  are  masked  by  the  preexisting 
disease.  In  the  plastic  form,  there  may  be  no  symptoms  or  at 
most  precordial  distress  or  pain  most  marked  at  the  xiphoid 
cartilage.  In  pericarditis  with  effusion,  the  presence  of  the  fluid 
may  cause  the  pain  above  mentioned;  moderate  fever,  101°  to 
103*  F.  or  exacerbation  of  an  already  existing  fever,  often  irregular, 
at  the  onset  of  pericardial  complications ;  rapid  heart  action  with 
feeble  irregular  pulse;  pressure  symptoms;  dyspnea,  dysphagia; 
irritative  cough;  aphonia;  hiccough;  nausea  and  vomiting;  disten- 
tion of  the  veins  of  the  neck  and  duskiness  of  the  face.  There 
may  be  great  restlessness,  melancholia,  delirium,  or  acute  mania, 
and  more  rarely  the  pulsus  paradoxus.  Absorption  is  usually  rapid 
but  the  heart  may  remain  irritable  for  a  long  time.     In  purulent 

135 


136  THE  PERICARDIUM 

pericarditis  the  diagnostic  points  are  the  same  as  in  the  fibrinous 
form  with  the  addition  of  septic  phenomena.  The  only  positive 
evidence  is  by  exploratory  puncture. 

More  rarely,  the  onset  of  pericarditis  is  indicated  by  rigors, 
remittent  fever,  frequently  nausea  and  vomiting,  precordial  dis- 
tress and  tenderness,  acute  shooting  pains,  increased  respirations 
and  a  dry,  suppressed  cough,  increased  cardiac  action,  sometimes 
violent  palpitation;  this  lasts  a  few  hours  to  a  day  or  two.  In 
children,  the  onset  is  often  insidious  and  may  precede  any  obvious 
signs  of  rheumatism. 

The  physical  signs  are  more  important  than  the  subjective 
symptoms  for  diagnosis. 

Before  the  effusion  of  fluid  the  excited  cardiac  action  with 
precordial  friction  fremitus  is  evident.  The  fremitus  becomes  less 
pronounced  as  the  effusion  increases  but  is  rarely  entirely  absent 
until  complete  resolution  takes  place. 

The  characteristic  **to-and-fro"  friction  rub  may  cause  scratch- 
ing, grating,  or  "new  leather"  creaking;  is  both  systolic  and  dias- 
tolic; has  its  point  of  maximum  intensity  in  the  third  or  fourth 
interspace  along  the  sternum  and  this  varies  with  the  position  of 
the  patient ;  is  localized  although  it  extends  more  or  less  over  the 
whole  cardiac  surface;  seems  near  to  the  ear,  is  modified  by  the 
pressure  of  the  stethoscope,  position  of  the  patient,  and  by  respira- 
tory movement. 

During  the  stage  of  effusion,  no  friction  sounds  are  present. 
The  heart  sounds  are  mufiied  and  feeble. 

Inspection  shows  precordial  prominence  with  widening  and 
bulging  of  the  lower  intercostal  spaces,  most  marked  in  the  fourth 
interspace  over  the  right  ventricle  and  increased  when  the  patient 
leans  forward.  The  bulging  increases  with  the  effusion.  When 
there  is  a  large  amount  of  effusion,  the  clavicle  is  elevated  with 
bulging  of  the  left  retroclavicular  space  so  that  the  first  rib  can 
be  palpated  to  the  sternum.  The  cardiac  impulse  may  be  feeble 
or  absent.  Tenderness  may  be  present.  The  apex  beat  is  dis- 
placed, according  to  the  amount  and  location  of  the  effusion.  The 
cardiac  dullness  is  increased  vertically  and  laterally. 

Many  "signs"  are  described,  but  the  exceptions  are  many,  and 
their  recognition  more  difficult  than  is  a  diagnosis  based  upon  a 
recognition  of  the  actual  condition  present  in  each  case. 

Reflex  muscular  contractions  usually  appear  first  in  the  region 
of  the  third  and  fourth  inter-spinous  areas.  These  increase  in 
area,  until  almost  the  entire  interscapular  region  is  involved.  Some- 
times only  the  deeper  spinal  layers  are  contracted ;  more  often  the 
superficial  layers  also,  and  the  intercostals,  especially  of  the  left 
side,  are  contracted  and  hypersensitive.  The  relief  of  these  reflex 
contractions  gives  comfort,  and  this  is  diagnostic  of  pericarditis  as 
distinguished  from  endocarditis.  * 


CHRONIC  PERICARDITIS  137 

Treatment.    Absolute  mental  and  physical  rest  in  bed  to  relieve 

the  heart  of  all  work  possible  is  essential.  Slow  the  heart  action 
by  deep,  steady  pressure  through  the  cervical  and  upper  dorsal 
areas  especially  at  the  fourth  and  fifth  dorsal  on  the  left  side. 
Correct  any  subluxations  found.  Pay  particular  attention  to  the 
atlas  and  the  structures  along  the  course  of  the  vagus.  The  ribs 
and  clavicle  must  be  carefully  attended  to  and  the  intercostal 
muscles  relaxed.  Relax  the  diaphragm.  Deep,  steady  pressure  at 
the  fourth,  fifth  and  sixth  cervical  areas  quiets  the  heart  action  for 
some  hours.  The  pain  about  the  heart  is  relieved  by  the  general 
treatment  but  if  especially  severe,  deep,  steady  pressure  at  the  first, 
second,  and  third  cervical  and  the  fourth,  fifth,  and  sixth  dorsal 
areas  is  indicated.  Dyspnea  is  allayed  by  the  treatment  as  out- 
lined and  by  raising  the  ribs.  When  the  pulse  becomes  weak 
and  cyanosis  occurs,  stimulation  of  the  heart  and  lungs  is  required, 
but  this  does  not  occur  unless  conditions  are  very  unfavorable.  In 
the  early  stages  an  ice  bag  to  the  precordium  will  aid  in  giving 
much  relief. 

Liquid,  diet,  principally  milk,  is  usually  given  at  first.  Later 
other  light  nutritious  food  may  be  added.  Dry  food  is  sometimes 
advised. 

Free  elimination  with  the  bowels,  kidneys,  and  skin  active 
must  be  secured  to  promote  absorption  of  the  fluid  after  the  acute 
stage  subsides  and  the  elimination  of  the  poisonous  waste  products. 

If  the  effusion  is  very  great,  producing  urgent  cardiac  symp- 
toms, paracentesis  or  incision  may  need  to  be  performed.  Drain- 
age is  necessary  in  purulent  cases. 

Prognosis.  This  depends  upon  the  cause.  In  simple  sero- 
fibrinous types  the  outlook  is  good  for  recovery  in  one  to  three 
weeks.  The  greater  the  amount  of  fluid,  the  more  grave  is  the 
prognosis.  Permanent  damage  may  result  from  complication  with 
endocarditis  or  m3^ocarditis  or  from  the  formation  of  extensive 
adhesions.  In  purulent  or  hemorrhagic  pericarditis  the  prognosis 
is  grave.  Pericarditis  complicating  pneumonia  or  renal  disease  is 
often  fatal.    Relapses  are  not  infrequent. 

Sequelae.  Greater  or  less  degree  of  adhesion  occurs  in  most 
cases.  These  adhesions  may  lead  to  hypertrophy,  or  may  merely 
add  to  the  cardiac  difficulty  in  later  pathological  states. 

CHRONIC  ADHESIVE  PERICARDITIS 

(Adherent  pericardium) 

Chronic  adhesive  pericarditis  in  any  degree  may  result  from 
acute  pericarditis,  varying  with  the  amount  of  effusion.  If  there 
are  simply  adhesions  between  the  visceral  and  parietal  layers 
usually /there  are  no  recognizable  symptoms.     When  the  inflam- 


138  THE  PERICARDIUM 

mation  becomes  more  chronic  and  extends  to  the  mediastinum  and 
pleura,  the  parietal  pericardium  may  become  adherent  to  the 
pleura  and  chest  wall.  It  is  more  often  found  in  young  people. 
The  subjective  and  objective  symptoms  are  interdependent. 

Diagnosis.  The  precordia  is  prominent.  There  is  an  indraw- 
ing  of  the  interspaces,  at  the  time  of  the  ventricular  systole,  most 
marked  at  the  apex  and  synchronous  with  the  systolic  shock. 
There  is  also  a  systolic  retraction  of  the  left  back  in  the  region 
of  the  eleventh  and  twelfth  ribs. 

Diaphragm  Phenomena  of  Broadbent.  There  is  a  visible  sys- 
tolic tug  communicated  through  the  diaphragm  to  its  points  of 
attachment,  the  seventh  or  eighth  rib  in  the  left  parasternal  line 
and  on  the  left  side  behind  the  eleventh  and  twelfth  ribs.  The 
apex  is  displaced  outward  and  the  area  of  impulse  is  increased, 
both  due  to  the  cardiac  hypertrophy.  The  apex  is  fixed,  not 
changing  with  the  different  positions  of  the  patient.  The  impulse 
is  undulatory,  wavy  and  in  the  apex  region.  Diastolic  rebound  of 
the  chest  wall  is  characteristic  of  pericardial  adhesions.  Fried- 
reich's Sign — (the  collapse  of  the  cervical  veins  during  diastole) 
and  pulsus  paradoxus — (the  pulse  becoming  smaller  at  the  end 
of  inspiration)  are- characteristic.  The  area  of  cardiac  dullness  is 
increased,  usually  upward  even  to  the  first  interspace;  this  is  not 
modified  by  respiration. 

When  the  membrane  over  the  right  ventricle  is  most  affected, 
there  may  be  very  marked  systemic  disturbances.  The  hepatic 
engorgement  may  simulate  cirrhosis  of  the  liver — pseudo-cirrhosis 
• — there  may  be  gastro-intestinal  disturbances  which  cloud  the 
diagnosis  greatly.  When  the  pericardium  over  the  left  ventricle 
is  most  affected,  pulmonary  disturbances — dyspnea,  cough,  etc., 
may  be  so  marked  as  to  simulate  pulmonary  disease. 

PERICARDITIS  CALLOSA.  This  is  a  form  of  chronic  pericarditis 
which  appears  insidiously  during  childhood.  It  is  very  hard  to  recognize  before 
death,  but  should  be  suspected  in  children  with  symptoms  of  hepatic  cirrhosis, 
edema  or  ascites,  full  jugulars,  or  cyanosis.  The  treatment  is  that  of  pericarditis 
in  adults,  when  the  condition  is  recognized.  Its  prevention  depends  upon  care 
during  convalescence  from  the  acute  fevers,  and  upon  the  maintenance  of  a 
suitable  diet  and  hygienic  regime  for  children ;  rheumatic  tendencies  are  per- 
haps especially  to  be  avoided.  Bony  lesions  of  etiological  importance  include 
those  affecting  the  cardiac  centers,  and  these  should  be  corrected  by  very  gentle 
movements,  avoiding  any  undue  irritation  of  the  nerve  endings  of  the  affected 
articular  surfaces.  Recovery  is  rare;  even  when  death  is  delayed  the  heart 
rarely  regains  full  functional  activity. 

Treatment.  In  most  cases  no  particular  treatment  is  needed 
for  chronic  pericarditis  since  the  heart  adapts  itself  to  the  conditions 
as  found  and  no  particular  symptoms  are  produced.  When  the 
condition  is  recognizable  treatment  may  be  necessary.  It  must 
be   remembered   that   the   adhesions   may   embarrass   the   heart's 


CHRONIC  PERICARDITIS  139 

action  to  such  an  extent  as  to  iead  to  hypertrophy  or  to  disturb- 
ances of  the  circulation.  These  adhesions  are  connective  tissue 
and  are  more  or  less  completely  covered  by  a  secreting  and  endo- 
thelial membrane.  If  attempts  are  made  to  stretch  or  to  break 
these  adhesions  the  irritation  upon  this  membrane  may  set  up  an 
acute  exacerbation  and  a  chronic  inflammation.  For  this  reason 
great  care  is  necessary  in  giving  treatments  or  exercises  which 
might  throw  tension  upon  the  pericardial  and  mediastinal  tissues. 
In  order  to  relieve  the  cardiac  embarrassment  the  following  pro- 
cedures may  be  modified  to  suit  individual  cases :  The  ribs  should 
be  raised  and  held  spread  apart  while  the  patient  takes  a  long 
breath.  This  should  be  done  with  the  patient  lying  upon  the  side, 
then  upon  the  back  and  then  upon  the  face  in  order  that  the  influ- 
ence of  gravity  may  be  allowed  to  act  from  as  many  different 
directions  as  possible.  The  lower  ribs  may  be  pulled  out  while 
the  patient  lies  upon  his  back  or  side  with  the  knees  drawn  up  in 
such  a  way  as  to  relax  the  abdominal  muscles.  This  may  be  done 
with  the  patient  in  the  knee-chest  position. 

Exercises  in  moderation  are  also  helpful.  The  patient  may  be 
taught  to  breathe  slowly  and  deeply  while  the  arms  are  extended 
strongly  upwards,  outwards  and  downwards ;  while  he  is  in  the 
knee-chest  position  lying  upon  the  right  side,  the  left  side,  the 
face  and  the  back.  All  of  these  exercises  and  manipulations  tend 
to  bring  gradual  and  gentle  tension  upon  the  pericardial  adhesions 
and  also  to  facilitate  the  cardiac  hypertrophy.  The  hygienic  con- 
ditions are  those  indicated  in  any  condition  requiring  cardiac  hyper- 
trophy. The  general  health  should  be  kept  as  good  as  possible 
and  all  structural,  infectious,  and  environmental  causes  for  dimin- 
ished vitality  should  be  removed. 

When  the  adhesions  seem  limited  to  the  region  of  the  apex,  and 
are  very  strong,  embarrassing  the  heart's  action  seriously,  their 
surgical  section  may  be  considered. 

HYDROPERICARDIUM.  '  Pericardial  dropsy  is  an  accumulation  of 
water  in  the  pericardial  sac  without  inflammation,  occurring  always  secondary 
to  cardiac  or  renal  disease,  pneumothorax,  pressure  of  an  aneurysm,  medias- 
tinal tumors,  or  diseased  cardiac  veins,  clinically  marked  by  pressure  symptoms, 
precordial  distress,  disturbed  cardiac  action,  dyspnea,  dry  cough,  and  dysphagia, 
and  the  physical  signs,  those  of  effusion  without  any  friction  sound  ever  being 
present. 

The  fluid  varies  from  an  ounce  to  one  or  two  pints,  is  clear,  yellowish  or 
straw-colored,  and  alkaline  in  reaction. 

The  diagnosis  is  made  by  the  history  and  by  aspiration  of  the  fluid.  The 
treatment  is  that  of  the  underlying  cause.  If  the  cardiac  action  is  greatly 
embarrassed,  paracentesis   may  be  performed. 

HEMOPERICARDIUM.  Hemopericardium  is  found  in  rupture  of 
aneurysm  of  the  first  part  of  the  aorta,  of  the  cardiac  wall,  of  the  coronary 
arteries,  and  in  rupture  and  wounds  of  the  heart. 

Death  usually  follows  before  there  is  time  for  the  production  of  symptoms 
other  than  those  of  rapid  heart  failure  due  to  compression. 


140  THB  PERICARDIUM 

PNEUMOPERICARDIUM.  (Air  in  the  pericardium.)  Rarely  wounds, 
fistulae,  gas-producing  bacteria,  may  result  in  the  presence  of  atmospheric  air 
or  carbon-dioxid  in  the  pericardial  sac.  The  symptoms  are  those  of  pericarditis, 
purulent  or  with  effusion.  A  tympanitic  note  over  the  heart,  which  changes  with 
the  position  of  the  patient;  splashing,  "water  wheel"  sounds,  synchronous  with 
the  pulse,  make  the  diagnosis  fairly  positive. 

The  treatment  is  the  same  as  for  purulent  pericarditis,  with  which  it  is 
usually  associated.  The  prognosis  is  always  very  grave,  and  death  is  to  be 
expected  within  a  very  few  days. 

CHRONIC  POLYSEROSITIS  (Pick's  disease).  In  this  rather  rare 
disease  the  serous  membranes  become  thickened  through  the  proliferation  of  the 
cells  of  their  connective  tissue  framework.  The  pericardium  becomes  greatly 
thickened,  and  its  layers  adherent.  The  pleura  and  peritoneum  undergo  sim- 
ilar changes ;  the  splenic  and  hepatic  capsules  are  greatly  thickened,  with  symp- 
torns  of  cirrhosis  of  both  organs.  The  cardiac  symptoms  are  usually  first 
noticed  and  most  conspicuous. 

Treatment  is  limited  to  palliative  measures.  Such  spinal  corrections  as  are 
indicated  on  examination  facilitates  the  best  circulation  and  elimination  pos- 
sible under  the  circumstances.  Paracentesis  may  be  indicated,  if  the  ascites 
becomes  annoying. 

Prognosis.  These  patients  may  live  for  years,  with  varying  discomfort. 
Recovery  is  probably  impossible.  Death  is  usually  due  to  some  intercurrent 
disease,  as  pneumonia. 


CHAPTER  XIV  .    ^ 

DISEASES  OF  THE  MYOCARDIUM 

ACUTE  MYOCARDITIS 

(Acute  interstitial  myocarditis;  carditis;  abscesses  of  the  heart) 
Acute  myocarditis  is  rapid  degeneration  of  the  cardiac  muscle 
or  an  extension  of  a  septic  pericarditis  or  endocarditis  usually- 
occurring  in  connection  with  the  infectious  fevers,  clinically  char- 
acterized by  the  sudden  appearance  of  cardiac  failure  and  usually 
quickly  fatal.  Rarely  the  infectious  agent  is  introduced  into  the 
heart  by  trauma. 

Diagnosis.  During  convalescence  from  some  acute  disease,  or 
after  the  occurrence  of  pericarditis,  dyspnea,  sighing,  syncope  and 
precordial  oppression  occur;  the  pulse  becomes  rapid  and  weak, 
but  rarely  irregular;  the  face  is  pale;  the  hands  cold,  and  other 
signs  of  depressed  circulation  are  noted ;  occasionally  collapse  and 
coma  follow;  the  heart  sounds  are  feeble,  sometimes  the  first 
sound  is  accentuated,  the  cardiac  impulse  and  the  apex  beat  may 
be  imperceptible. 

Treatment.  This  depends  upon  the  conditions  as  found  on 
examination.  Absolute  rest,  physical  and  mental,  is  indicated. 
Even  turning  in  bed,  or  lifting  an  arm,  or  slight  excitement,  may 
be  immediately  fatal.  Very  gentle,  steady  pressure  near  the  spines 
of  the  tenth  thoracic  to  the  second  lumbar  vertebrae  relieves  the 
cardiac  strain ;  this  should  be  repeated  two  or  three  times  each  day. 

The  most  important  therapeutic  consideration  is  prevention. 
During  the  course  of  the  infectious  fevers,  or  in  any  pyemic  proc- 
ess, the  condition  of  the  heart  should  be  watched  carefully;  any 
violent  exertion  during  convalescence  is  to  be  avoided.  The  cor- 
rection of  the  bony  lesions  associated  with  the  cardiac  nerve 
centers  should  be  a  routine  procedure  in  all  acute  fevers,  pneu- 
monia, the  puerperal  state,  rheumatism,  or  other  conditions  liable 
to  affect  the  heart  in  any  way. 

Prognosis.  The  disease  is  usually  rapidly  fatal ;  death  is  to  be 
expected  in  a  few  hours  to  six  days  after  the  first  symptoms  are 
noticed. 

CHRONIC  INTERSTITIAL  MYOCARDITIS 

(Fibrous  myocarditis;   fibroid  heart;   chronic   carditis;   cardiosclerosis) 
Chronic  interstitial  myocarditis  is  a  slowly  developing  change 
in   the  heart  musculature  due  to  hyperplasia  and  induration  of 

141 


142  ^  THE.  MYOCARDIUM 

the  connective  tissues.  It  is  characterized  by  more  or  less  dyspnea 
on  exertion,  tachycardia  or  bradycardia,  precordial  distress  and 
pain,  and  symptoms  of  anemia  of  various  organs.  It  often  pre- 
sents no  symptoms. 

Etiology.  The  conditions  responsible  for  general  arterio-scle- 
rosis  may  also  be  responsible  for  interstitial  myocarditis.  The 
inorganic  poisons  such  as  phosphorus,  lead  or  mercury ;  the 
overuse  of  stimulating  foods  and  drinks,  especially  alcohol ;  and 
the  organic  toxins  of  syphilis,  gout,  rheumatism,  malaria,  diabetes, 
nephritis,  carcinoma,  and  so  on,  are  all  important  etiological  fac- 
tors. Bony  lesions  are  indirectly  responsible  through  causing 
increased  blood  pressure  or  preventing  the  proper  elimination  of 
the  products  of  katabolism. 

Pathology.  This  condition  bears  a  direct  relation  to  the  arteries 
throughout  the  body  and  especially  to  the  coronary  arteries.  The  primary 
changes  in  the  coronary  arteries  may  be  either  acute  or  chronic  arteritis, 
atheroma,  or  endarteritis  obliterans  of  syphilitic  origin,  both  forms  being  factors 
in  causing  thrombosis  of  a  large  branch.  Embolism  of  the  coronary  artery 
results  in  sudden  death. 

The  heart  is  enlarged  and  dilated,  the  structural  changes  being  either  dif- 
fused or  localized  in  the  walls  of  the  left  ventricle,  the  papillary  muscles  and 
the  septum. 

Diagnosis.    The  symptoms  are  nearly  all  cardiac  in  character. 

Heart-tire  is  out  of  all  proportion  to  other  evidences  of  old 
age.  It  is  indicated  by  breathlessness  on  exertion,  slight  cyanosis, 
puffiness  or  edema  of  the  ankles  and  v^eakness  out  of  proportion 
to  the  appearance  of  the  patient.  Cerebral  symptoms  include  gid- 
diness, vertigo,  syncope,  insomnia,  pseudo-epileptic  attacks  on  ris- 
ing from  the  recumbent  position,  pseudo-apoplexy,  rarely  mania, 
delusional  attacks,  or  dementia.  Dry  hacking  cough ;  dyspepsia 
and  constipation ;  scanty  albuminous  urine  and  dropsy  indicate  the 
generally  impaired  circulation. 

Tachycardia,  150  to  180  per  minute,  may  be  a  terminal  cardiac 
sign  of  myocarditis.  Bradycardia  is  much  more  frequent,  between 
30  and  50  per  minute,  and  may  be  associated  with  Stokes-Adams 
syndrome,  rarely  with  angina  or  severe  arrhythmia.  Death  results 
from  syncope^  Arrhythmia  with  feeble  pulse  may  be  the  only 
clinical  symptom.  Anginal  attacks  vary  from  great  distress  to 
true  angina.  (See  Angina  pectoris.)  There  is  a  sallow,  pallid 
complexion,  and  evidences  of  premature  age  as  shown  by  hair, 
baggy  eyelids  and  abundance  of  wrinkles. 

The  examination  of  the  heart  shows  a  feeble  impulse  at  times 
scarcely  felt,  the  apex  beat  not  palpable  or  displaced  to  left;  area 
of  absolute  dullness  increased ;  dilated  hypertrophy.  The  sounds 
are  feeble,  the  first  sound  more  or  less  valvular.  There  is  a  char- 
acteristic irregularity  of  force  and  rhythm.  Murmurs  are  frequent 
and  due  to  valve  lesions.  There  may  be  gallop  rhythm  or  redupli- 
cation of  the  systolic  sounds  best  heard  at  fourth  rib  in  parasternal 


MYOCARDITIS    '  143 

line  and  more  marked  in  the  recumbent  position  and  after  exer- 
cise. Added  signs  are  found  when  hypertrophy  or  dilation  become 
marked. 

The  arteries  are  palpable,  tortuous  vessels  with  thick  walls  and 
high  tension ;  the  temporal  artery  is  prominent  and  the  arcus 
senilis  is  often  present.     Blood  pressure  is  increased. 

Exercise  has  little  effect  upon  functional  disturbances,  but 
increases  the  pain,  dyspnea,  cardiac  disturbances  when  the  myo- 
cardium is  degenerated. 

Treatment.  There  is  no  remedy  for  the  fibroid  change,  but 
the  fibrosis  may  be  held  in  check  and  the  symptoms  met  or  pre- 
vented by  improving  nutrition,  preventing  constipation,  guarding 
against  any  mental  strain  or  physical  exertion,  by  diet,  and  by 
careful  systematic  treatment.  t 

The  removal  of  every  factor  responsible  for  abnormally  high 
blood  pressure  or  for  the  retention  of  the  toxic  products  of  metab- 
olism may  prevent  the  more  rapid  course  of  the  disease.  The 
symptoms  may  be  treated  as  they  arise.  Stimulation  of  the  accel- 
erators in  the  upper  dorsal  and  the  sympathetics  in  the  cervical 
region  increase  the  strength  of  beat  and  tone  of  the  heart  muscle. 
The  heart  must  be  watched  very  carefully  during  this  treatment, 
and  for  some  hours  afterward.  The  palpitation,  dyspnea,  arrhyth- 
mia, and  depressed  circulation  are  relieved  by  raising  the  ribs, 
and  by  long,  slow,  gentle  movements  of  the  lower  thoracic  spinal 
column.  Inhibition  of  the  splanchnics  is  often  useful.  For  pseudo- 
apoplexy,  the  patient  is  placed  recumbent  with  the  head  slightly 
raised,  and  the  whole  spine  treated  with  careful  relaxation  and 
correction,  paying  particular  attention  to  the  cervical  area.  The 
blood  pressure  may  be  equalized  by  deep,  steady  pressure  to  the 
splanchnics  and  to  the  solar  plexus  direct.  All  secretions  must  be 
kept  active.    Pay  attention  to  the  kidney  area. 

Diet  must  be  generous  and  of  easily  digested  foods.  Little  or 
no  tea  or  coffee  must  be  given.  Tobacco  and  alcohol  are  absolutely 
forbidden.  The  patient  should  lie  down  several  hours  during  the 
day.  Exercise  must  be  carefully  gauged  by  the  effect  upon  the 
pulse,  blood  pressure,  and  the  cardiac  signs.  The  following  may 
be  used,  beginning  with  the  first  and,  as  followed  by  improvement, 
each  advance  may  be  taken:  (a)  massage;  (b)  resistance  move- 
ments; (c)  moderate  walking  on  the  level;  (d)  light  gymnastics. 

The  Nauheim  treatment  may  be  of  benefit  but  must  be  given 
very  carefully  and  in  selected  cases. 

After  improvement,  the  patient  should  return  for  osteopathic 
examination  every  few  months.  ^  little  occasional  attention  may 
be  of  very  great  value  in  prolonging  a  comfortable  life. 

Prognosis.  This  is  largely  determined  by  the  habits  of  the 
patient.     The  disease  is  incurable  but  the  patient  may  Jive  fairly 


144  THE  MYOCARDIUM 

comfortably  for  many  years  if  he  will  observe  due  care.  This  is 
one  of  the  most  common  causes  of  heart  failure  in  the  course  of 
acute  pneumonia,  typhoid  fever,  and  from  overexertion. 

Prevention  is  important.  The  paragraphs  on  etiology  and 
treatment  suggest  the  best  methods  for  avoiding  the  disease. 

FATTY  DEGENERATION 

Fatty  degeneration  of  the  heart  is  a  change  of  the  cardiac 
muscle  fibers,  the  transverse  striae  being  replaced  by  granules  or 
globules  of  fat.  It  is  clinically  characterized  by  feeble  cardiac 
action,  venous  stasis,  and  dyspnea. 

Etiology.  It  is  a  disease  of  elderly  people  and  follows  those 
diseases  which  induce  fatty  changes,  as  carcinoma;  tuberculosis; 
chronic  gout ;  prolonged  anemia ;  kidney  diseases ;  prolonged  admin- 
istration of  chemical  poisons  as  arsenic,  phosphorus  or  alcohol ; 
lack  of  out-door  exercise;  and  chronic  intestinal  toxemia.  It  may 
follow  fatty  infiltration. 

Diagnosis.  The  symptoms  are  often  obscure.  There  may  be 
coldness  of  the  feet,  drowsiness  after  meals,  dyspnea  on  exertion, 
syncopal  or  even  epileptiform  attacks.  Angina  pectoris  may  occur. 
Cheyne-Stokes  breathing,  sighing  or  oscillating  respiration  may 
cause  fright.  Cardiac  asthma  and  arcus  senilis  are  sometimes 
present. 

The  physical  signs  include  a  weak,  irregular  cardiac  impulse; 
cardiac  dullness  normal  or  very  moderately  enlarged,  first  sound 
feeble,  toneless,  and  almost  inaudible;  second  sound  normal  or 
weak ;  pulse  often  remarkably  slow,  compressible,  sometimes  irreg- 
ular.   It  is  associated  with  atheromatous  changes  in  the  vessels. 

Diagnosis  is  rarely  more  than  probable.  It  is  to  be  distin- 
guished from  fibroid  degeneration. 

Treatment.  The  removal  of  the  etiological  factors  is  important, 
when  this  is  possible.  The  treatment  outlined  for  chronic  myo- 
carditis should  be  adapted  to  the  needs  of  each  individual  patient. 
A  quiet  life  is  imperative.    Errors  in  diet  must  be  avoided. 

Prognosis.  Recovery  is  not  to  be  expected,  and  death  may 
occur  at  any  time,  from  cardiac  paralysis,  rupture  of  the  heart,  or 
exhaustion.  Life  may  be  prolonged  and  made  more  comfortable 
by  correct  hygiene  and  such  treatment  as  is  indicated  by  the  con- 
dition of  the  patient. 

FATTY  INFILTRATION 

Fatty  infiltration  myocarditis  is  an  excess  of  fat  between  the 
muscle  fibers  and  around  the  heart.  It  is  associated  with  general 
obesity  and  evidences  of  cardiac  weakness.  <* 


DILATATION  145 

Diagnosis.  There  are  no  symptoms  until  the  muscle  fibers  are 
so  weakened' that  dilatation  occurs  with  its  particular  signs.  The 
heart  sounds  are  weak  and  muffled;  a  murmur  may  be  present  at 
the  apex  and  the  pulse  is  feeble  and  regular;  these  conditions 
exist  for  years.  Diagnosis  is  made  by  the  presence  of  obesity  and 
the  evidences  of  cardiac  weakness,  without  signs  of  other  cardiac 
disease. 

Treatment.  In  this  case  much  can  be  done  if  the  heart  muscle 
has  not  been  too  badly  weakened.  The  main  object  is  to  reduce 
the  fat.  (See  Obesity.)  The  treatment  for  chronic  myocarditis 
may  be  adapted  to  the  condition  of  the  patient. 

Prognosis.  In  young  people  the  prospect  is  good  for  sympto- 
matic recovery,  though  such  persons  must  be  careful  not  to  allow 
too  great  increase  in  the  body  fat,  during  their  remaining  life. 
Elderly  persons  must  be  careful  not  to  reduce  weight  too  rapidly; 
such  individuals  may  suffer  serious  cardiac  symptoms,  even  death, 
as  the  result  of  rapid  loss  of  weight.  If  the  fatty  deposit  is  con- 
tinued, or  if  the  patient  refuses  obedience  to  hygienic  laws,  per- 
manent injury  to  the  cardiac  muscle  follows.  Sudden  death  may 
occur  from  rupture,  or  with  symptoms  of  heart  block. 

DILATATION  OF  THE  HEART 

(Cardiac  dilatation) 

Dilatation  of  the  heart  is  an  increase  in  the  size  of  one  or 
more  of  its  cavities  without  hypertrophy.  It  is  characterized  by 
feebleness  of  the  circulation,  terminating  in  venous  stasis,  cyanosis, 
edema,  and  exhaustion,  and  is  most  typically  seen  in  the  broken 
compensation  of  aortic  and  mitral  regurgitation. 

Etiology.  It  is  due  to  causes  which  directly  affect  the  myo- 
cardium as  bacterial  toxins,  chemical  poisons  or  prolonged  pyrexia. 
Increased  pressure  within  the  walls,  emotion,  shock,  and  physical 
exertion,  especially  running  or  bicycling  uphill,  mountain  climbing, 
etc.,  cause  sudden  or  acute  dilatation.  In  those  of  feeble  resistance 
slight  causes  are  effective.  It  sometimes  seems  to  be  idiopathic. 
It  occurs  secondarily  in  chronic  valvular  lesions,  chronic  bron- 
chitis, chronic  interstitial  nephritis,  alcoholism,  and  syphilis. 
Among  the  predisposing  causes  are  fatty  and  fibroid  degenera- 
tions of  the  muscle,  and  inadequate  nutrition. 

Diagnosis.  The  general  symptoms  are  referable  to  enfeebled 
circulation ;  feeble  pulse,  headache  aggravated  by  the  upright  posi- 
tion, attacks  of  syncope,  cough,  dyspnea,  jaundice,  dyspepsia,  con- 
stipation, scanty  often  albuminous  urine,  mental  dullness,  vertigo 
often  relieved  by  copious  epistaxis,  and  finally  dropsy  beginning 
in  the  lower  extremities.  If  these  changes  take  place  slowly,  it  is 
termed  "gradual  failure  of  compensation." 


146  THE  MYOCARDIUM 

The  precordial  throbbing  and  extended,  wavy  impulse;  the 
small,  weak,  irregular  pulse ;  the  increased  dullness  of  square  out- 
line, the  diminution  or  loss  of  the  muscular  element  of  the  first 
sound,  should  make  the  diagnosis  apparent.  In  general,  if  there 
are  no  valvular  lesions,  the  cardiac  sounds  are  weaker,  the  systolic 
sounds  sharper,  short,  and  of  high  pitch.  The  X-ray  shows  large 
"thin"  heart-shadow  with  characteristic  shape  distorted  according 
to  cavity  involved. 

Treatment.  The  object  of  treatment  is  to  secure  hypertrophy, 
if  possible.  Correction  of  the  subluxations  is  important,  especially 
those  affecting  the  cardiac  and  vasomotor  centers.  Active  elimina- 
tion by  all  emunctories  must  be  maintained.  The  diet  must  be 
liberal  and  as  nutritious  as  the  patient  can  assimilate.  Digestive 
disturbances  must  be  avoided.  Rest  from  business,  excitement, 
and  physical  strain  is  essential.  There  are  various  systems  of 
exercise  devised,  among  which  may  be  mentioned :  Swedish  or 
Ling  plan  of  passive  exercise  and  massage,  Schott  movements 
against  limited  resistance,  and  Oertel's  climbing  method. 

Prognosis.  The  outlook  depends  upon  the  amount  of  hyper- 
trophy to  be  secured.  Otherwise  the  prognosis  is  very  unfavor- 
able, death  resulting  sooner  or  later  from  exhaustion  or  from 
cardiac  paralysis. 

CARDIAC  HYPERTROPHY 

(Hypertrophy  of  the  heart) 

Cardiac  hypertrophy  is  an  increase  in  the  number  and  size  of 
muscle  cells  of  the,  heart,  induced  by  overwork  of  the  heart  from 
whatever  cause  and  characterized  by  forcible  cardiac  impulse  and 
accelerated  circulation. 

Etiology.  Among  the  predisposing  causes  are :  valvular  and 
especially  aortic  lesions ;  adherent  pericardium ;  diseases  of  the 
lungs ;  increased  peripheral  resistance  as  a  result  of  arteriosclerosis 
or  chronic  interstitial  inflammations ;  aneurysm  of  the  aorta ;  over- 
exertion of  the  healthy  heart  (athletic  heart)  ;  long-continued  stim- 
ulation due  to  the  neuroses,  exophthalmic  goitre,  or  the  long-con- 
tinued use  of  large  quantities  of  tea,  coflfee,  or  tobacco. 

Pathology.  The  hypertrophy  is  usually  limited  to  the  ventricles,  the 
left  side  being  more  commonly  involved.  The  auricles  have  not  so  much  mus- 
cular tissue  and  so  dilate  more  readily  than  hypertrophy.  The  shape  is  altered. 
If  the  left  ventricle  is  chiefly  involved,  the  heart  is  elongated  and  the  cavity 
dilated;  if  the  right  ventricle  is  the  more  implicated,  it  is  widened  transversely 
and  the  apex  blunted;  if  both  ventricles,  the  shape  becomes  globular.  From 
increase  in  weight,  the  heart  may  drop  back  when  the  patient  is  recumbent, 
but  on  sitting  or  standing  it  sinks  lower  in  the  chest  and  to  the  left  causing 
more  or  less  prominence  of  the  abdomen. 

The  varieties  are  (1)  simple  hypertrophy  which  is  a  simple  increase  in  the 
thickness  of  the  cardiac  walls ;  and  (2)  eccentric  or  dilated  hypertrophy  which 
is  increase  in  the  walls  with  dilatation  of  one  or  more  cavities. 


HYPERTROPHY  147 

Diagnosis.  If  the  hypertrophy  is  only  sufficient  to  compensate 
for  defects,  there  are  no  symptoms.  The  degree  of  hypertrophy 
depends  largely  upon  the  age  of  the  patient.  If  it  is  disproportion- 
ate to  the  obstacle,  there  is  increased  and  forcible  cardiac  action, 
precordial  discomfort,  headache,'  dizziness  on  exertion,  tinnitus 
aurium,  flushes,  flashes  of  light,  dyspnea  on  exertion,  conges- 
tion of  the  face  and  eyes,  dry  cough,  epistaxis,  restless  nights,  and 
more  or  less  jerking  of  the  limbs. 

When  the  hypertrophy  is  concomitant  with  general  arterioscle- 
rosis, the  arteries  become  full  and  the  pulse  firm  and  bounding,  the 
carotids  and  superficial  arteries  pulsate  markedly  so  that  the  patient 
complains  of  throbbing  sensations. 

If  the  disease  began  early  in  life,  there  is  bulging  of  the  pre- 
cordium ;  if  after  adult  life,  fullness  and  prominence  with  a  distinct 
impulse  is  seen.  The  cardiac  impulse  is  felt  one  or  two  inter- 
spaces lower  and  to  the  left,  stronger,  slower,  more  or  less  diflfused 
and  forcible,  more  "heaving,"  than  normal.  The  apex  beat  may  be 
felt  in  the  sixth,  seventh,  or  eighth  interspaces  even  three  inches 
outside  of  the  mid-mammary  line.  The  pulse  is  full,  strong,  regu- 
lar, and  of  increased  tension.  It  is  modified  according  to  the 
valvular  lesions  present. 

The  increased  area  of  dullness  extends  vertically  and  trans- 
versely to  left  of  sternum ;  if  the  right  ventricle  involved,  dullness 
is  increased  to  right  of  sternum.  X-ray  shows  enlarged  "thick- 
ened" shadow. 

If  there  are  no  valvular  changes,  the  first  sound  is  loud,  pro- 
longed, of  low  pitch,  and  of  a  somewhat  dull  or  metallic  quality. 
The  second. sound  is  strongly  accentuated,  clear  and  loud.  Asso- 
ciated valvular  disease    causes  varying  murmurs. 

The  sequelae  of  left  ventricular  hypertrophy  are  cerebral  hemor- 
rhage, miliary  cerebral  aneurysms,  fatty  degeneration  or  cardiac 
dilatation. 

Hypertrophy  of  the  Right  Ventricle  is  due  to  chronic  valvular 
lesions  of  right  or  left  heart,  or  pulmonary  diseases  as  emphysema 
and  cirrhosis.  Bulging  over  the  lower  part  of  sternum  and  occa- 
sionally over  the  sixth  and  seventh  left  costal  cartilages  is  present. 
Epigastric  pulsation  may  be  seen  in  third  and  fourth  interspaces 
to  right  of  sternum.  The  radial  pulse  is  of  small  volume.  The 
cardiac  dullness  is  moderately  increased  transversely  and  to  the 
right. 

There  is  accentuation  of  the  second  pulmonic  sound  due  to 
increased  tension  of  the  pulmonary  artery.  Reduplication  of  the 
second  cardiac  sound  may  occur. 

Auricular  Hypertrophy  is  always  combined  with  dilatation.  In 
the  left  auricle  the  signs  are  few  and  indefinite ;  dullness  to  left 
of  sternum,  in  the  second  and  third  interspaces  with  a  presystolic 


148  THE  MYOCARDIUM 

impulse  or  wave  in  the  second  space.  This  is  inferred,  if  mitral 
stenosis  or  regurgitation  is  present.  In  the  right  auricle,  hyper- 
trophy is  always  with  dilatation  and  is  secondary  to  incompetency 
or  stenosis  of  the  tricuspid  valve  and  associated  with  right  ven- 
tricular hypertrophy  and  dilatation.  The  main  signs  are:  dullness 
in  the  third  and  fourth  interspaces  to  right  of  sternum,  with  often 
a  presystolic  wave  in  same  area,  systolic  jugular  pulsation  and 
evidences  of  venous  engorgement. 

Treatment.  Remove  the  cause  if  possible.  If  excessive,  lessen 
the  force  and  number  of  cardiac  pulsations  by  deep  steady  pressure 
at  the  third  and  fourth  dorsal  vertebrae,  correcting  any  lesions 
present.  Note  the  position  of  first  ribs,  clavicles,  and  lower  ribs. 
Correct  the  habits  of  the  patient,  according  to  conditions  as 
found.  All  active  exertion  should  be  restricted  and  the  recum- 
bent position  assumed  several  hours  during  the  day  if  possible. 
The  diet  must  be  carefully  regulated,  nutritious,  yet  all  kinds  of 
stimulating  foods  interdicted. 

Prognosis.  The  outlook  depends  upon  the  original  cause.  If 
the  hypertrophy  is  compensatory  for  valvular  lesions,  the  duration 
and  comfort  of  life  may  not  be  affected.  Further  hypertrophy  can 
usually  be  prevented  by  active  and  persistent  treatment,  unless  the 
original  cause  increases  in  severity. 

CARDIAC  MISPLACEMENTS.  These  may  be  congenital  or  acquired. 
Transposition  of  the  heart  may  be  associated  with  transposition  of  the  abdominal 
viscera  or  it  may  exist  alone.  Transposition  does  not  in  the  least  interfere  with 
perfectly  normal  function ;  it  is  rarely  recognized  ante  mortem  and  no  treatment 
whatever  is  possible  or  necessary. 

The  position  of  the  heart  may  be  changed  by  variations  in  the  position  or 
the  structure  of  other  thoracic  viscera.  The  right  lung  may  be  destroyed  by 
abscess  or  otherwise  and  the  left  lung  may  increase  in  size  to  such  an  extent  as 
to  pull  the  heart  well  over  to  the  right  side. 

Rarely  a  weakness  of  the  suspensory  tissues  permits  the  heart  to  change 
its  position  when  changing  position  of  the  body  of  the  patient.  This  possibility 
must  be  kept  in  mind  when  making  a  diagnosis  of  cardiac  hypertrophy  and  dilata- 
tion. The  diagnosis  rests  upon  finding  the  different  locations  of  the  cardiac 
dullness  when  the  patient  assumes  different  positions.  Roentgen  ray  gives 
valuable  geography  and  is  positive. 

INJURIES  OF  THE  HEART 

Although  very  trivial  injuries  to  the  heart  usually  result  in 
death,  yet  it  occasionally  happens  that  recovery  occurs  from 
wounds  of  considerable  size.  In  addition  to  bullet  and  stab  wounds 
and  other  gross  trauma,  a  number  of  cases  have  been  reported  in 
which  the  heart  has  been  invaded  by  needles  and  other  sharp 
objects.  In  several  cases  a  needle  has  been  found  embedded  in 
scar  tissue  in  the  wall  of  the  heart,  sometimes  with  a  part  of  its 
length  projecting  into  the  ventricle.  Surgical  repair  of  the  injured 
heart  is  possible. 


DISEASED  ARTERIES  149 

CARDIAC  NEOPLASMS 

It  is  very  rare  that  the  heart  or  its  membranes  are  the  seat  of 
new  growths  of  any  kind.  The  diagnosis  is  frequently  impossible 
ante  mortem,  although  it  occasionally  happens  that  metastatic 
growths  may  be  expected.  The  vegetations  upon  the  valves  of  the 
heart  are  not  to  be  considered  in  any  sense  as  neoplasms. 

Increase  in  the  cardiac  dullness  with  a  weak  heart  beat  and 
other  signs  of  cardiac  embarrassment,  together  with  cachexia  and 
other  systemic  indications,  may  give  the  diagnosis,  especially  if 
the  cardiac  neoplasm  is  secondary  to  recognized  malignancy  else- 
where. No  treatment  is  of  any  value  and  death  is  speedy,  in  all 
cases  in  which  any  cardiac  symptoms  are  present. 

CARDIAC  ANEURYSM 

Aneurysm  of  the  wall  of  the  heart  may  occur  as  the  result  of 
disease  of  the  coronary  vessels,  myocardial  degeneration  or  sud- 
den increase  in  blood  pressure  in  a  heart  whose  walls  are  weak- 
ened. The  sac  may  be  barely  perceptible  or  it  may  be  as  large  as 
the  patient's  head.  Attempt  at  repair  is  made  by  the  coagulation  of 
the  blood  in  the  sac  and  the  organization  of  the  clot.  The  con- 
dition is  not  usually  recognized  before  death  and  the  only  treat- 
ment is  that  of  the  predisposing  causes. 

Aneurysm  of  the  valves  may  occur  in  endocarditis.  The  sac 
may  be  of  considerable  size  without  producing  any  recognized 
symptom. 

If  aneurysm  of  the  wall  of  the  heart  or  of  another  large  vessel 
becomes  ruptured  sudden  death  occurs. 


DISEASED  CORONARY  ARTERIES 

The  symptoms  associated  With  disease  of  the  coronary  arteries 
and  to  a  certain  extent  of  the  vessels  of  Thebesius  are  fairly  typi- 
cal. Any  of  the  ordinary  degenerations  affecting  the  walls  of  blood 
vessels  may  be  seen  in  the  branches  of  the  coronary  arteries  and 
when  any  of  these  pathological  changes  result  in  the  occlusion  of 
any  of  the  arterial  twigs  an  infarct  is  produced  whose  after  history 
may  follow  either  of  two  definite  paths.  Coronary  arteries  are 
terminal  and  there  is  very  slight  opportunity  for  overlapping  of 
areas  of  distribution.  When  the  circulation  is  partially  supplied 
and  perhaps  under  certain  other  conditions  the  muscle  cells  un- 
dergo gradual  atrophy  and  there  is  a  multiplication  of  the  con- 
nective tissue  elements  throughout  the  infarct  area,  the  condition 
resembles  a  little  mass  of  scar  tissue  in  the  middle  of  the  cardiac 
muscle.  This  condition  is  known  as  the  white  infarct,  and  when 
a  number  of  such  accidents  occur  the  heart  assumes  the  mottled 


150  THE  MYOCARDIUM    ■ 

appearance  which  sometimes  receives  the  name  of  "marble  heart." 
Under  other  circumstances  the  cardiac  muscle  undergoes  soften- 
ing and  may  be  absorbed;  in  any  of  these  cases  the  wall  of  the 
heart  is  greatly  weakened. 

At  the  time  of  the  occlusion  of  the  vessels  the  patient  suflFers 
very  severe  pain  in  the  precordium  and  the  symptoms  of  angina 
pectoris  may  occur.  At  other  times  there  is  a  dizziness  or  per- 
haps sj-ncope.  The  symptoms  depend  upon  the  size  of  the  arteries 
occluded. 

The  condition  terminates  by  sudden  death.  Sometimes  the  wall 
of  the  heart  ruptures,  more  frequently  on  the  anterior  aspect  of 
the  left  ventricle,  and  sometimes  the  occlusion  of  one  of  the  larger 
branches  of  one  of  the  coronary  arteries  produces  death. 

Treatment.  At  the  time  of  the  shock  the  patient  should  rest 
for  several  hours  or  several  days  in  bed.  He  must  avoi^  sudden 
exertion,  violent  emotion,  excitement  and  all  the  conditions  which 
ordinarily  raise  blood  pressure.  -  ' 

The  prophylaxis  is  far  more  important.  It  consists  in  avoiding 
all  of  those  factors  which  cause  arteriosclerosis  or  myocarditis. 

ANGINA  PECTORIS 

(Breast-pang;  stenocardia;  neuralgia  of  the  heart) 

Angina  pectoris  is  an  affection  characterized  by  sudden  attacks 
of  agonizing  pain  in  the  cardiac  region  and  a  sense  of  impending 
death. 

Etiology.  The  predisposing  causes  include  all  conditions  which 
interfere  with  the  nutrition  of  the  walls  of  the  heart,  particularly 
in  men  past  middle  life ;  among  these  nutritive  influences  being 
mentioned  affections  of  the  cardiac  ganglia  and  plexuses.  Syphilitic 
aortitis  is  a  factor  in  men  .under  thirty-five  years.  Spinal  luxations 
which  have  been  found  in  these  cases  are  those  of  the  atlas,  the 
cervical  region  and  the  upper  dorsal  area.  Lesions  of  the  fourth 
thoracic  are  reported  in  connection  with  coronary  spasm. 

The  exciting  causes  are  sudden  strain,  over-distended  stomach, 
powerful  emotional  disturbances,  gout,  diabetes,  and  influenza. 

Disturbance  of  the  coronary  circulation  is  the  one  factor  to  be 
considered.  This  is  due  to  some  obstructive  lesion  in  the  typical 
case.  Spasm  of  the  coronary  arteries  produces  exactly  the  same 
symptoms,  and  is  not  to  be  differentiated  from  the  effects  of 
obstructive  lesion,  in  most  cases.  Probably  functional  spasm  is 
associated  with  the  true  obstructive  lesion  very  often ;  there  is  no 
doubt  that  functional  spasm  predisposes  to  coronary  disease  and 
thus  to  obstruction. 

Diagnosis.  There  is  a  sudden  seizure  with  acute  intensely 
agonizing  pain  with  a  sense  of  constriction  across  the  chest  or  of 


ANGINA  PECTORIS  151 

suffocation,  the  patient  stops  whatever  he  is  doing,  grasps  some- 
thing if  handy,  and  stands  perfectly  still.  The  terrible  feeling  of 
anxiety  and  anguish  is  shown  in  the  face.  The  pain  is  most  marked 
at  the  lower  end  of  the  sternum,  radiates  into  the  neck  and  down 
the  left  arm,  more  rarely  into  the  right  arm.  It  follows  the  course 
of  the  ulnar  nerve.  There  is  referred  pain  in  the  region  of  the 
fifth,  sixth,  and  seventh,  even  the  eighth  and  ninth  dorsal  vertebrae 
and  also  pain  in  the  cervical  region.  Muscles  in  this  region  are 
tense  and  hypersensitive.  The  respiration  is  very  shallow  and  diffi- 
cult although  there  is  no  obstruction  to  the  entrance  of  air  into 
the  lungs.  The  face  is  very  pale,  even  gray,  with  no  cyanosis. 
The  whole  body  is  covered  with  a  cold  sweat.  The  pulse  may 
show  increased  tension.  The  attack  may  last  a  few  seconds  to 
many  minutes,  leaving  the  patient  prostrated.  An  excessive  flow 
of  urine  follows  the  attack.  It  may  terminate  fatally  at  the  first 
attack  or  may  recur  at  intervals,  the  first  being  mild  and  those 
following  increasing  in  severity. 

Some  cases  present  all  the  symptoms  except  pain  (angina  sine 
dolore).  Other  cases  are  associated  with  coldness  and  pallor  of 
the  extremities  (angina  pectoris  vasomotoria),  the  pain  being  com- 
paratively slight. 

Angina  vera  is  most  common  in  men  past  middle  life;  is  often 
brought  on  by  exertion ;  is  rarely  nocturnal  or  periodic ;  is  not  asso- 
ciated with  other  symptoms ;  the  pain  is  agonizing  and  attended  by 
a  sense  of  constriction,  and  is  of  short  duration.  The  patient  pre- 
sents an  attitude  of  silence  and  immobility ;  arteriosclerosis  is 
present  and  the  prognosis  is  grave-;  attacks  often  proving  fatal. 

Pseudo-angina  is  hysterical.  It  is  most  common  in  women  of 
any  age  from  childhood,  attacks  are  spontaneous,  often  periodical 
and  nocturnal,  and  associated  with  other  hysterical  symptoms. 
The  pain  is  less  severe,  with  a  sense  of  distention  instead  of  con- 
striction, duration  is  one  or  more  hours,  is  attended  by  agitation 
and  activity,  and  is  never  fatal. 

Treatment.  The  patient  should  be  put  to  bed  as  soon  as  an 
attack  seems  impending.  The  first  object  is  to  relieve  the  pain 
by  raising  the  left  lower  ribs  over  the  cardiac  area,  pressure  being 
made  at  the  same  time  over  the  upper  three  dorsal  transverse 
processes.  Apply  deep  steady  pressure  to  the  vagus  in  the  neck 
and  relax  the  precordial  intercostal  tissues.  If  the  attack  is  exceed- 
ingly severe  or  continued  for  some  time,  a  few  whiffs  of  chloroform 
may  be  necessary  to  secure  relaxation.  An  ice  bag  over  the  heart 
usually  gives  relief;  hot  applications  are  more  effective  in  occa- 
sional cases. 

Interval  treatment.  Careful  attention  to  the  general  nutrition 
and  elimination  is  necessary  to  improve  the  nutrition  of  the  heart 
muscle.   Cases  with  spasm  of  the  coronary  arteries  due  to  lesions  of 


152  THB  MYOCARDIUM 

the  fourth  or  other  thoracic  vertebrae  are  apt  to  recover  after  cor- 
rection of  the  lesion.  If  the  condition  has  not  been  too  long  present, 
recovery  is  complete;  in  cases  of  long  standing  recovery  may  be 
slower,  or  the  changes  in  the  vessel  walls  may  not  permit  com- 
plete recovery,  though  the  symptoms  are  greatly  relieved.  This 
correction  is  best  made  during  the  intervals  of  the  attacks — the 
shock  of  sudden  correction  is  apt  to  perpetuate  the  attack  if 
attempts  are  made  at  that  time. 

In  obstructive  cases,  the  eflfects  of  the  associated  spasm  are 
not  to  be  neglected,  so  that  the  same  corrective  measures  are  indi- 
cated, whether  there  is  or  is  not  reason  to  infer  a  true  obstructive 
angina.  Passive  exercises  and  general  massage  may  be  gently 
given  by  the  nurse. 

A  strict  milk  diet  may  be  necessary  at  first  until  the  general 
nutrition  is  improved  and  toxins  removed.  The  general  diet  should 
include  plenty  of  fresh  vegetables  and  fruits,  eggs,  dairy  products, 
lean  meat  in  great  moderation,  and  plenty  of  pure  drinking  water 
unless  other  symptoms  indicate  water  restriction.  Tobacco,  alco- 
hol, tea  and  coffee  are  to  be  forbidden.  Rest  in  bed  for  some  weeks 
is  sometimes  useful.  Mental  and  muscular  overstrain  are  to  be 
avoided  in  all  cases.  Cold  baths  are  dangerous,  but  hot  ones  are 
useful.  Hot  foot-baths  on  retiring  may  give  full  night's  sleep.  The 
boWels  should  receive  careful  attention.  Strenuous  enemas  are 
harmful.     Purgative  drugs  should  be  absolutely  forbidden. 

The  prognosis  is  fairly  good  for  recovery  from  the  attack  but 
is  ultimately  fatal  in  organic  cases.  Cases  due  to  spasm  of  the 
vessels  often  recover,  apparently  completely. 


CHAPTER  XV 
THE  CARDIAC  NEUROSES 

It  is  often  extremely  difficult  to  draw  the  line  between  those 
cardiac  symptoms  due  to  nervous  disturbances  and  those  due  to 
organic  or  mechanical  causes.  Purely  neurotic  heart  action  is 
usually  associated  with  disturbed  vasomotor  activity.  Probably 
every  case  of  organic  disease  of  the  heart  or  blood  vessels  is  com- 
plicated by  more  or  less  marked  disturbances  in  the  nervous  con- 
trol of  the  cardiac  and  vascular  muscles. 

Etiology.  The  etiology  of  the  cardiac  neuroses  depends  upon 
those  factors  which  modify  the  action  of  the  heart  centers  in  the 
medulla  and  in  the  upper  thoracic  spinal  cord  or  over  the  nerve 
trunks  and  ganglia  by  means  of  which  nerve  impulses  are  trans- 
mitted to  the  heart.  The  place  of  the  bony  lesions  has  already 
been  mentioned. 

Neurotic  inheritance  is  usually  present  and  the  stigmata  of 
hysteria  are  frequently  found.  The  use  of  alcohol,  tobacco,  tea, 
coffee,  or  of  excessive  meat  or  starch  eating  are  etiological  factors 
of  varying  importance.  Emotional  disturbances  beyond  the  normal 
limits  are  responsible  for  the  palpitation  especially. 

Diagnosis.  The  diagnosis  of  the  cardiac  neuroses  must  be  made 
by  the  exclusion  of  all  organic  diseases,  not  only  of  the  heart  and 
blood  vessels,  but  also  of  other  organs  capable  of  affecting  the 
heart.  The  ductless  glands,  the  kidneys,  the  blood  itself,  the  liver, 
the  stomach,  the  pelvic  organs,  must  also  be  carefully  examined 
before  the  diagnosis  of  a  cardiac  neurosis  can  safely  be  made. 

Treatment.  The  treatment  has  already  been  indicated  by  what 
has  been  said  of  the  etiology.  The  character  of  the  bony  lesions 
as  found  upon  the  examination  of  each  patient  is  by  far  the  most 
important  factor  in  uncomplicated  cases.  Increased  nutrition  of 
the  body,  and  especially  better  circulation  through  the  spinal  cord 
and  the  lower  brain  centers,  are  also  important.  Complete  rest  is 
often  necessary  for  the  acute  attacks.  In  patients  with  hysteric 
or  neurasthenic  symptoms  the  treatment  suitable  for  these  dis- 
eases must  be  employed. 

Prognosis.  In  uncomplicated  cases  the  prognosis  for  speedy 
recovery  is  very  good  indeed,  provided  suitable  treatment  is  given. 

Without  treatment  the  life  of  the  patient  is  not  in  danger  but 
his  comfort  and  efficiency  are  considerably  lessened  by  the  disturbed 
heart  action.    Whether  these  functional  disturbances  may  lead  to 

153 


154  ,  THB  CARDIAC  NEUROSES 

organic  diseases  of  the  heart  later  in  life  is  a  question  which  is  not 
yet  answered;  a  priori,  it  is  to  be  supposed  that  the  effects  of 
functional  disturbances  might  predispose  to  organic  disease. 

Palpitation  of  the  heart  is  characterized  by  increased  force  of 
the  heart  beat  which  causes  uncomfortable  sensations  in  the  cardiac 
region,  often  throbbing  in  the  temples,  the  throat  and  abdomen. 
It  is  more  frequently  associated  with  bony  lesions  of  the  upper 
cervical  region  although  lesions  in  the  interscapular  spinal  column 
are  not  rare.    Digestive  disturbances  may  be  exciting  causes. 

BRADYCARDIA 

(Unusually  slow  heart  beat) 

Extremely  low  pulse,  35  to  50>  may  be  found  in  persons  who  are 
otherwise  normal.  Purely  functional  bradycardia  must  be  distin- 
guished from  the  slow  pulse  which  is  present  in  certain  forms  of 
cardiac  hypertrophy  and  especially  in  diseases  characterized  by 
the  presence  of  toxic  substances  in  the  blood  stream.  Jaundice 
and  toxemia  from  the  absorption  of  the  toxic  productions  of  intes- 
tinal putrefaction  are  especially  to  be  noticed  in  this  connection. 
The  bony  lesions  usually  found  in  the  purely  functional  bradycar- 
dia include  especially  those  of  the  second  to  the  fourth  thoracic 
vertebrae  and  the  regions  associated  with  these.  Upper  rib  lesions 
and  upper  cervical  lesions  are  occasionally  found  in  these  cases. 

Treatment.  Bradycardia  due  to  nervous  disturbance,  bony 
lesions,  and  the  milder  forms  of  toxemia  can  be  relieved  by  pres- 
sure upon  the  vagus  nerve  in  the  neck,  or  by  stimulating  move- 
ments applied  to  the  tissues  near  the  third  and  fourth  thoracic 
spinous  processes  and  to  the  deeper  spinal  muscles  of  these  seg- 
ments. 

For  relief  of  attacks,  the  patient  should  be  given  warm  or  hot 
drinks,  hot  applications  to  the  abdomen  and  limbs,  and  all  constrict- 
ing clothing  should  be  removed.  Correction  of  the  bony  lesions 
as  found  should  be  thorough,  both  for  the  effect  upon  the  heart 
itself,  and  for  the  relief  of  the  underlying  toxemia,  nerve  reflexes, 
and  other  causative  factors  which  may  be  present.  Stimulating 
manipulations  to  the  mid-thoracic  region  and  the  suboccipital 
triangles  may  relieve  the  attack. 

TACHYCARDIA 

(Unusually  rapid  heart  beat) 

This  may  be  present  as  an  individual  idiosyncrasy,  as  a  cardiac 
neurosis,  in  exophthalmic  goiter,  or  as  a  symptom  of  disease  of  the 
heart  muscle.  Not  rarely  a  pulse  of  100  to  140  may  be  found  in 
individuals  apparently  in  perfect  health.     The  sp%ed  may  be  due 


ARRHYTHMIA  155 

to  shortened  rest  period  or  to  increased  rapidity  of  the  entire  car- 
diac cycle.  In  polysystole,  the  interval  between  the  first  and  sec- 
ond sounds  is  normal,  while  the  rest  period  is  shortened.  In 
cmbryocardia,  the  interval  between  the  first  and  second  sounds, 
and  also  the  rest  period,  are  shortened. 

If  tachycardia  can  be  relieved  by  stimulating  the  vagus  nerve 
in  the  neck,  or  by  steady  pressure  over  the  suboccipital  triangles, 
or  near  the  spinous  processes  of  the  third  and  fourth  thoracic  ver- 
tebrae, it  is  of  extracardiac  origin — which  may  include  exophthal- 
mic goiter,  the  efifects  of  bony  lesions,  or  other  cardiac  neurosis. 
If  these  manipulations  do  not  modify  the  pulse  rate,  after  thorough 
testing,  the  heart  muscle  is  probably  diseased.  In  some  cases  of 
exophthalmic  goiter,  also,  it  is  not  possible  to  affect  the  heart  by 
these  manipulations. 

Treatment.  Correction  of  the  lesions  of  the  third  and  fourth 
thoracic  vertebrae  and  the  associated  ribs,  and  of  the  cervical 
vertebrae,  the  first,  second,  fifth  and  sixth  ribs,  especially  on  the 
left  side,  when  these  are  found,  is  of  importance.  In  reflex  or  sys- 
temic nervous  cardiac  disturbances,  the  relief  of  the  cause  of  the 
neurosis  is  of  primary  importance.  For  the  attacks,  the  patient 
should  be  taught  to  lie  with  the  head  low,  take  a  full  breath,  and 
hold  the  glottis  closed  to  the  limit  of  comfortable  endurance.  Com- 
pressing the  abdomen  gives  relief.  Pressure  upon  the  tissues  near 
the  third  and  fourth  vertebrae  is  palliative. 

ARRHYTHMIA 

(Arrhythmia  cordis;  irregularity  of  the  pulse) 

Normally,  the  contraction  of  the  heart  originates  at  the  sino- 
auricular  node,  at  the  mouth  of  the  superior  vena  cava,  is  con- 
ducted to  the  auricle,  and  hence  to  the  ventricle  by  way  of  the 
auriculo-ventricular  bundle  (bundle  of  His  or  Gaskell's  ridge). 
Under  conditions  of  abnormal  stimulation,  contractions  may  orig- 
inate in  the  auriculo-ventricular  node  in  the  wall  of  the  right  ven- 
tricle near  the  coronary  sinus ;  or  in  the  auriculo-ventricular  bundle 
on  the  ventricular  side  of  the  node;  or  in  the  auricular  tissue  itself. 

Etiology.  The  main  causes  are  valvular  and  myocardial  dis- 
eases; rheumatism  and  chorea;  long-continued  excessive  use  of 
tobacco,  tea,  or  coffee ;  flatulent  dyspepsia ;  the  nervous  conditions 
of  neurasthenia,  hysteria,  and  melancholia,  or  of  organic  disease  of 
the  nervous  system. 

Subluxations  especially  at  the  anterior  ends  of  the  first  to  the 
fifth  ribs,  or  the  fourth  and  fifth  dorsal  vertebrae  may  irritate  the 
heart  and  cause  a  simple  arrhythmia. 

There  are  several  types  of  irregularity. 


156  THB  CARDIAC  NEUROSES 

Sinus  Irregularity  begins  at  the  sino-auricular  node.  The  beats 
are  irregular,  equal  in  size,  but  with  a  variable  diastolic  period. 

Extra-Systole  is  the  commonest  form.  There  is  premature  con- 
traction of  the  auricle  or  ventricle  or  both,  independent  of  the  sinus 
rhythm.  The  sinus  stimulation  then  occurs  during  the  refractory 
period  and  the.  diastole  is  prolonged  until  the  next  sinus  stimula- 
tion is  due.  This  accounts  for  many  cases  of  intermission,  pulsus 
bigeminus  or  trigeminus  and  delirium  cordis. 

Auricular  Fibrillation  is  a  condition  in  which  the  auricular  mus- 
cle fibers  contract  rapidly  and  inco-ordinately  producing  an 
arrhythmia  with  no  regularity  or  sequence.  A  ventricular  venous 
pulse  can  be  seen  in  the  neck.  The  condition  is  especially  frequent 
in  mitral  stenosis  and  in  the  senile  heart.  Irregularity  occurs  when 
there  is  a  failure  in  the  conducting  power  of  the  primitive  bundle, 
the  ventricular  systole  being  occasionally  omitted. 

"Pulsus  Alternans  shows  itself  by  a  comparatively  regular  alter- 
nation of  strong  and  weak  beats.  It  needs  be  but  briefly  consid- 
ered here,  as  it  can  rarely  be  determined  except  by  instrumental 
means.  When  recognized  it  is  generally  accepted  as  an  ill  omen. 
As  a  prognostic  sign  it  compares  with  such  others  as  albuminuric 
retinitis,  signifying  that  but  a  brief  period  of  life  can  be  expected." 
— M.  W.  Peck. 

It  is  due  to  depression  or  failure  of  the  contractile  power  of 
the  ventricle. '  Many  intermissions  are  functional  and  may  be 
habitual  and  unrecognized. 

The  treatment  and  prognosis  depend  upon  the  cause  of  the 
arrhythmia  and  not  upon  its  severity.  Organic  disease  with  almost 
unrecognizable  symptoms  may  occasion  speedy  death ;  functional 
arrhythmia  wjiich  is  very  severe  may  be  followed  by  perfect  recov- 
ery under  suitable  treatment  of  the  causes. 

STOKES-ADAMS  DISEASE 

(Heart  block) 

This  is  the  term  applied  to  the  effect  produced  by  diseases  of  the 
muscular  bundle  of  His. 

Pathology.  The  bundle  of  His  which  transmits  the  impulse  from  the 
auricles  to  the  ventricles  is  composed  of  muscular  tissue  which  retains  embryonic 
characteristics  throughout  life,  it  is  therefore  somewhat  more  easily  subject 
to  disease  than  is  the  rest  of  the  heart  muscle.  When  it  undergoes  degenera- 
tion, the  contraction  wave  arising  around  the  roots  of  the  great  veins  in  the 
auricles  passes  with  difficulty  to  the  ventricular  walls ;  for  this  reason  the 
auricles  may  beat  twice  or  even  three  or  four  times  to  every  single  ventricular 
systole.    The  condition  is  most  easily  recognized  by  the  jugular  pulsation. 

Diagnosis.  Simultaneous  tracings  taken  of  the  jugular  and 
radial  pulsations  usually  give  the  diagnosis  without  question. 


STOKES-ADAMS  DISEASE  157 

Treatment.  The  cause  of  the  cardiac  degeneration  should  be 
removed  if  this  is  possible.  Stimulating  foods  and  drinks,  over- 
work and  emotional  strain  must  be  avoided,  all  structural  causes  of 
cardiac  malfunction  must  be  removed.  Rest  in  bed  at  the  time  of 
the  exacerbations  is  necessary. 

Prognosis.  The  prognosis  is  grave  for  all  cases  of  Stokes- 
Adams  disease,  usually  death  is  imminent  when  the  diagnosis  is 
made. 

Congenital  heart-block  is  a  rare  condition,  probably  due  to  the 
imperfect  development  of  the  bundle  of  His.  It  is  recognized  by 
the  history  of  congenital  defect;  the  missed  ventricular  beats  asso- 
ciated with  rhythmical  jugular  pulsation,  and  the  absence  of  find- 
ings diagnostic  of  other  cardiac  defects.  In  one  case  recorded 
(P.  C,  O.  Clinic)  development  or  compensation  occurrejd,  so  that 
at  least  a  symptomatic  recovery  prevented  further  symptoms. 

CARDIAC  ASTHMA.  These  attacks  are  characteristic  and  apt  to  come- 
on  in  the  early  morning  hours.  The  patient  is  suddenly  seized  with  dyspnea; 
the  respirations  are  labored,  not  much  increased  in  frequency  but  the  distress 
is  extreme ;  rattling  sounds  come  from  fluid  in  the  bronchi ;  clear  fluid  pours 
from  the  mouth  or  is  easily  discharged;  if  death  is  near,  it  is  discharged  with 
difficulty,  if  at  all.  The  patient  sits  upright  with  pallid  face,  sweat-covered 
forehead,  and  cold  pallid  hands.  The  temperature  is  subnormal,  the  blood 
pressure  low,  the  pulse  is  rapid,  thready,  irregular  and  often  scarcely  per- 
ceptible at  the  wrist,  the  patient  being  in  a  state  of  profound  shock.  The  heart 
sounds  are  heard  only  as  a  confused  jumble  with  irregular  or  ineffectual 
systoles,  the  lung  sounds  overshadowing  the  cardiac.  In  the  interval  after 
recovery  from  attack  the  patient  will  remain  fairly  free  from  dyspnea.  The 
pulmonary  edema  present  is  usually  due  to  impairment  of  the  pneumogastric 
nerve.     The  cause  is  not  known.     It  is  often  associated  with  chronic  nephritis. 

With  this  form,  death  usually  results  witiun  a  year  although  patients  have 
lived  several  years. 


CHAPTER  XVI 
DISEASES  OF  THE  ENDOCARDIUM 

•   ACUTE  FIBRINOUS  ENDOCARDITIS 

(Exudative  endocarditis;   valvulitis;   endocarditis  verrucosa) 

Acute  fibrinous  endocarditis  is  an  inflammation  of  the  lining 
membrane  of  the  cavity  of  the  heart,  the  valves  being  the  most 
commonly  affected.  It  is  characterized  by  the  formation  of  fibrous 
nodulations  upon  the  surface  called  vegetations;  the  clinical  symp- 
toms may  be  practically  negative.  Murmurs  variously  placed  upon 
the  cardiac  cycle  give  the  diagnosis. 

Etiology.  It  is  rarely  primary.  Secondarily,  it  is  found  most 
commonly  in  acute  rheumatism,  also  in  chorea,  tonsillitis,  scarlet 
fever,  pneumonia,  phthisis,  kidney  diseases,  and  occasionally  in 
gonorrhea,  in  the  cachexias  and  in  subluxations  affecting  the  car- 
diac centers.     Pyorrhea  alveolaris  may  be  important. 

Pathology.  Cloudiness  is  followed  by  edematous  thickening  of  the  valvu- 
lar endocardium,  superficial  erosions  and  the  formation  of  small  granulations, 
deposit  of  layers  of  fibrin,  blood  corpuscles,  and  a  few  organisms.  The  whole 
process  results  in  the  formation  of  small  friable  warty  outgrowths — vegetations. 
These  are  most  marked  one  or  two  millimeters  from  the  free  borders  at  the  line 
of  contact  of  the  leaflets.  In  the  course  of  time,  they  are  transformed  into 
fibrous  tissue.  The  myocardium  is  always  involved.  The  vegetations  are  upon 
the  side  of  the  valve  opposed  to  the  blood  stream ;  at  the  aortic  valve  they 
project  into  the  ventricle;  at  the  mitral,  into  the  auricle. 

The  location  is  significant.  Congenital  endocarditis  attacks  the  right  side 
of  the  heart;  simple  endocarditis  attacks  the  left  side;  malignant  endocarditis 
attacks  both  sides,  but  more  often  and  more  severely  the  left  side. 

Diagnosis.  The  subjective  symptoms  are  usually  negative  or 
vague,  since  in  most  fevers  the  heart  is  somewhat  dilated  and  a 
murmur  may  be  present  without  endocarditis.  In  severe  cases, 
there  may  be  irregular,  rapid,  feeble  pulse,  faintness,  pallor, 
increased  perspiration,  dyspnea,  precordial  pains,  throbbing  car- 
otids. Later  the  pulse  becomes  less  frequent  and  more  or  less 
-venous  stasis  and  pulmonary  congestion  appear.  Usually  a  sharp 
rise  in  temperature  in  the  course  of  the  primary  disease  without 
■other  causes,  leads  to  observation  of  the  heart.  Reflex  contractions 
of  the  deeper  spinal  muscles  of  the  second  to  the  fifth  thoracic 
segments  may  be  found  occasionally,  but  are  not  always  present. 
Their  occurrence  probably  depends  upon  an  associated  myo- 
carditis. 

The  most  reliable  physical  sign  is  the  development  of  a  rough- 
ened murmur,  like  soft  blowing,  with  the  first  sound  into  a  well- 

158 


ULCBRATIvn  ENDOCARDITIS  159 

marked  systolic  mitral  murmur,  during  rheumatism  or  acute  fevers. 
It  may  change  in  character  from  day  to  day  or  be  accentuated ; 
the  second  sound  may  be  reduplicated  at  apex  and  accentuated. 
Reduplication  and  accentuation  of  the  pulmonic  second  sound  is 
frequent.  The  new  sound  may  disappear  at  first  when  the  patient 
is  sitting  but  later  it  persists.  There  is  more  or  less  dilatation  and 
cardiac  irregularity.    All  cardiac  signs  may  be  latent. 

Complications.  As  the  vegetations  are  very  friable,  they  may 
become  detached.  These  emboli  produce  additional  symptoms 
according  to  the  location  of  the  end-artery  in  which  they  lodge. 

Embolism  of  the  kidneys  is  marked  by  sudden  deep-seated  lum- 
bar pain,  albuminuria,  even  hematuria.  Embolism  of  the  brain  is 
shown  by  sudden  palsies,  convulsions,  aphasia,  or  sudden  disturb- 
ances of  consciousness.  Embolism  of  the  spleen  usually  causes 
sharp  pain  and  tenderness  in  the  splenic  region.  Embolism  of  the 
skin  shows  in  petechial  or  purpuric  spots.  Embolism  of  the  lungs 
is  known  by  local  pain,  hemoptysis,  possibly  localized  dullness, 
bronchial  breathing  and  rales. 

Treatment.  Prevention  of  endocarditis  in  patients  with  the 
primary  diseases  is  important,  and  consists  in  guarding  them  from 
cold  and  undue  exertion.  The  correction  of  any  lesion  found  in 
the  cervical  and  upper  five  dorsal  vertebrae  and  the  ribs  at  their 
anterior  and  posterior  articulations,  relaxation  of  contracted  mus- 
cles, raising  and  spreading  the  ribs,  and  deep  steady  pressure  in 
the  sub-occipital  fossa  to  lower  the  fever  and  quiet  the  heart,  are 
some  of  the  measures  indicated.  Cold  over  the  cardiac  area  aids 
in  keeping  cardiac  action  slower. 

Absolute  bodily  and  mental  rest  for  weeks  or  months  is  neces- 
sary. The  diet  should  be  light  and  liquid.  The  bowels  and  kid- 
neys must  be  kept  active  to  eliminate  the  waste  metabolic  products. 

Prognosis.  Simple  endocarditis  without  complications  is  not 
dangerous  to  life.  The  affected  valve  usually  remains  damaged 
and  later  becomes  the  seat  of  chronic  endocarditis. 

ACUTE  AORTITIS.  This  disease  is  usually  associated  with  acute  endo- 
carditis with  which  it  is  usually  confused  in  diagnosis.  It  is  due  to  any  of  the 
infectious  diseases,  to  alcohol,  syphilis,  rheumatism,  etc.  The  pain  occurs  at 
a  somewhat  higher  level  than  is  the  case  in  endocarditis.  The  palpitation  may 
be  very  severe  but  symptoms  may  resemble  those  of  angina  pectoris.  The 
treatment  is  the  same  as  that  of  endocarditis;  recovery  is  usually  to  be  expected 
so  far  as  the  aortitis  is  concerned. 


MALIGNANT  OR  ULCERATIVE  ENDOCARDITIS 

The  malignant  form  may  be  primary  although  it  is  more  fre- 
quently secondary  to  septic  processes,  usually  in  connection  with 
a  suppurating  external  wound,  puerperal  sepsis,  acute  necrosis,  or 


160  '    THE  ENDOCARDIUM 

gonorrhea,  which  may  be  latent.    It  often  attacks  the  valves  which 
are  the  seat  of  chronic  inflammation. 

Pathology.  The  initial  changes  are  similar  to  the  simple  form  but  ulcera- 
tions may  completely  replace  the  vegetations.  The  vegetations  when  present 
are  larger  and  f ungating;  the  underlying  tissues  are  necrotic,  show  loss  of 
substance  and  round-celled  infiltration  and  contain  masses  of  bacteria.  When 
the  vegetations  become  detached,  they  form  septic  emboli  giving  rise  to  metas- 
tatic abscesses.  Ulcerative  process  causes  great  destruction  of  the  valves  and 
may  even  lead  to  perforation  of  the  curtain.  If  the  vegetation  touches  the 
mural  endocardium,  the  part  touched  becomes  affected  by  contact. 

Diagnosis.  The  patient  is,  and  appears,  extremely  ill.  Local 
symptoms  may  be  entirely  lacking,  and  cardiac  disturbance  may 
be  unsuspected  until  death  occurs.  In  the  "typhoid,"  the  most 
frequent  type,  the  symptoms  include  varying  degrees  of  vomiting 
and  diarrhea,  pain  in  the  hepatic  or  the  splenic  region ;  dimness  of 
vision;  hematuria  and  albuminuria;  irregular  chills  and  fever 
(sometimes  to  106°  F.) ;  ecchymoses  and  sweating;  and  the 
"typhoid  state." 

The  "cardiac  type"  (recurring  malignant  endocarditis)  is  char- 
acterized by  recurring  attacks  of  septic  endocarditis  in  a  heart 
with  valvular  lesions.  This  condition  should  not  be  confused  with 
the  simpler  attacks  of  recurring  simple  endocarditis. 

The  "cerebral  type"  symptoms  are  practically  those  of  cerebral 
meningitis. 

The  physical  signs  are  similar  to  those  of  the  simple  form. 
Variations  from  day  to  day  in  the  character  of  the  murmurs  seem 
to  be  more  frequent.  Leucocytosis  is  usually,  but  not  always  pres- 
ent ;  there  may  be  blood  changes  indicative  of  the  primary  disease. 
Local  infection  should  be  sought  for  as  the  heart  disease  is  often 
due  to  a  latent  gonococcus  infection. 

The  treatment  is  similar  to  that  of  simple  endocarditis.  Removal 
of  the  sources  of  infection  is  a  major  consideration.  The  excretion 
of  the  poisons  formed  must  be  aided  by  every  possible  means. 
Stimulation  of  the  liver  aids  bowel  elimination  and  raises  the 
opsonic  index.  To  increase  the  comfort  of  the  patient  and  delay 
death  is  the  most  that  can  be  expected. 

Prognosis.  Cases  engrafted  upon  an  existing  cardiac  disease 
may  last  for  several  months;  complete  recovery  is  not  to  be  ex- 
pected. Death  may  occur  at  any  time,  or  being  delayed,  may  result 
from  intercurrent  disease. 


CHRONIC  ENDOCARDITIS 

(Sclerotic  endocarditis;   interstitial  endocarditis) 
This  is  frequently  limited  to  the  valvular  endocardium,  though 
the  mural  form  is  by  no  means  rare.    It  produces  various  forms  of 
valvular  defects,  according  to  the  various  etiological  and  localizing 


CHRONIC  ENDOCARDITIS  161 

factors  present.     It  may  be  chronic  from  the  beginning,  or  may 
result  from  the  acute  form. 

Etiology.  Primarily,  the  disease  results  from  syphilis,  malaria, 
rheumatism,  lead,  alcohol,  and  other  infections  and  poisons;  or 
from  arteriosclerosis,  interstitial  nephritis,  muscular  strain,  and 
such  mechanical  agencies.  Hereditary  and  congenital  defects  are 
to  be  considered.  Secondary  chronic  endocarditis  is  associated 
with  rheumatism  and  tonsillitis,  most  frequently ;  and  with  chorea, 
pneumonia,  and  the  exanthematous  fevers. 

Pathology.  The  left  heart  is  far  more  commonly  affected,  the  valvular 
more  often  than  the  mural  membrane.  The  myocardium  usually  is  also  affected 
to  some  extent  in  the  latter  case  especially. 

There  is  sclerosis  of  the  valves,  with  formation  of  small  firm  nodular 
prominences,  and  of  yellowish  opaque,  fatty  patches,  often  deposition  of  cal- 
cium salts,  the  cusps  may  be  adhered  or  rigid  and  curled,  and  the  chordae 
tendinese  are  shortened  and  thickened  or  adhered. 

As  a  result  of  the  changes  mentioned,  the  valves  become  variously  thick- 
ened and  adherent.  The  contraction  of  the  chordae  tendineae  modify  the 
structural  changes.  Thus  is  produced  the  "funnel  mitral,"  the  "buttonhole 
mitral,"  the  "annular  mitral,"  etc.  The  term  "chronic  endocarditis"  should  be 
Hmited  to  those  cases  in  which  there  is  a  progressive  inflammation,  and  not  be 
applied  to  valvular  lesions  in  which  no  further  change  is  occurring. 

Diagnosis.  The  location  of  the  most  serious  changes  is  usually 
determined  bj'  the  recognition  of  the  valves  most  affected;  mural 
endocarditis  can  only  be  strongly  suspected  when  symptoms  of 
cardiac  distress  follow  acute  endocarditis.  The  symptoms  are 
mostly  those  of  a  slowly  increasing  valvular  defect,  with  increas- 
ing hypertrophy  which  seems  hardly  able  to  compensate  for  the 
defect.  Mild  leucocytosis  is  present  in  nearly  every  case.  Mild 
secondary  anemia  is  to  be  expected.  Other  blood  findings,  and  the 
urinary  findings,  depend  upon  the  effects  produced  by  the  circula- 
tory disturbance  on  other  organs,  and  this  depends  upon  the  valve 
most  seriously  affected. 

Reflex  muscular  contractions  are  not  present,  or  are  negligible, 
so  long  as  the  inflammation  is  limited  to  the  endocardium.  Peri- 
cardial and  myocardial  inflammations  may  complicate  the  endo- 
carditis, and  thus  reflex  contractions  be  produced  in  the  deep  spinal 
muscles  innervated  from  the  second  to  the  fourth  thoracic  seg- 
ments. The  intercostals  are  not  usually  affected  unless  the  peri- 
cardium is  inflamed  also. 

Treatment.  First,  is  to  be  considered  the  prophylaxis.  Patients 
with  conditions  ordinarily  considered  etiologic  factors  in  endo- 
carditis should  be  guarded  against  further  heart  disturbances. 
Patients  recovering  from  rheumatism,  tonsillitis,  pneumonia,  or  the 
exanthematous  fevers  should  be  watched,  and  not  permitted  to  sit 
up,  or  after  leaving  bed,  to  undertake  any  strenuous  exercise  until 
the  heart  is  well  strengthened  and  the  nerve  centers  have  regained 
their  normal  activity.    Correction  of  the  lesions  affecting  the  heart 


162  THU  ENDOCARDIUM 

centers,  if  any  are  found,  is  important.  Lesions  affecting  the  action 
of  kidneys  or  liver  or  intestinal  tract  may  permit  toxemia — this 
must  be  guarded  against  in  all  cases. 

The  treatment  of  acute  endocarditis,  as  already  given,  may  also 
be  considered  prophylactic  for  the  chronic  type.  When  chronic 
endocarditis  is  recognized,  the  treatment  depends  to  some  extent 
upon  the  extent  and  the  location  of  the  valvular  injury.  There 
are  certain  factors  that  are  applicable  to  all  lesions.  These  include 
^properly  graded  rest  and  exercise;  suitable  diet,  according  to  the 
patient's  needs,  and  his  digestion  and  elimination ;  and  the  mainte- 
nance of  correct  structural  conditions  of  the  body. 

Prognosis.  The  outlook  is  doubtful,  so  long  as  the  endocarditis 
persists.  After  inflammation  ceases,  the  nature  of  the  valvular 
lesions  permits  a  more  or  less  hopeful  prognosis  according  to  the 
conditions  as  found.  In  the  mural  type  the  injury  to  the  myo- 
cardium may  be  serious ;  this  is  not  easily  determined.  The  possi- 
bility of  mural  injury  should  be  kept  in  mind  in  every  case  in 
which  the  cardiac  embarrassment  presents  unusual  features.  (See 
also  valvular  lesions.) 


VALVULAR  LESIONS 

Injury  to  the  valves  of  the  heart  varies  fjrom  changes  so  light 
as  to  cause  no  recognizable  symptoms,  to  those  so  severe  as  to 
result  in  sudden  death. 

Etiology.  Congenital  weakness  may  permit  a  sudden  rise  in 
blood  pressure,  due  to  muscular  strain,  emotional  storms,  or  other 
causes,  to  rupture  a  valve  not  previously  diseased.  Such  condi- 
tions are  rarely  found.  In  practically  every  case  injury  to  a  valve 
is  primarily  due  to  inflammation.  Rheumatism,  tonsillitis,  pyor- 
rhea, chorea,  the  infectious  fevers,  are  the  most  common  causes 
of  endocarditis,  with  resulting  valvular  lesion ;  the  cardiac  valves 
may  share  the  effects  produced  upon  the  circulatory  system  by  the 
presence  of  poisonous  substances  in  the  blood  stream,  such  as  are 
present  in  alcoholism,  autointoxication  of  any  type,  syphilis,  etc., 
or  to  poisoning  by  lead,  mercury,  and  other  drugs,  or  as  the  result 
of  chronic  infections  in  the  body  anywhere.  Overwork,  too  little 
exercise,  too  little  fresh  air,  too  much  food  and  faulty  food,  and 
all  the  unhygienic  habits  usually  considered  causative  of  arterio- 
sclerosis and  of  acute  and  chronic  endocarditis  are  also  causative 
of  valvular  lesions. 

Diagnosis.  According  to  the  structural  changes  produced,  each 
valve  may  present  three  variations  in  normal  action ;  narrowed 
orifice,  causing  stenosis  (obstruction)  ;  imperfect  closure,  permit- 
ting regurgitation  (incompetency,  insufficiency),  or  the  valves  may 


MITRAL  REGURGITATION  163 

close  imperfectly  over  the  narrowed  orifice,  causing  symptoms  of 
both  states. 

The  diagnosis  of  the  different  valves  must  be  considered  sepa- 
rately; the  treatment  of  valvular  lesions  will  be  considered 
together,  since  many  factors  are  alike  in  all  cases. 


MITRAL  REGURGITATION 

This  is  the  most  frequent  form  of  valvular  lesion.  The  contrac- 
tion and  narrowing  of  the  leaves  of  the  valves,  with  or  without 
contraction  of  the  chordae  tendinese,  results  in  a  reflex  of  blood 
into  the  right  auricle.  This,  becoming  distended,  hypertrophies. 
Ventricular  hypertrophy  results  from  the  associated  muscular 
activity.  If  the  left  auricle  is  unable  to  overcome  the  back  flow, 
it  dilates,  the  lungs  become  congested,  and  the  right  ventricle 
hypertrophies.  The  somewhat  congested  condition  with  embar- 
rassed action  of  the  right  heart,  engorgement  of  the  lesser  circula- 
tion and  congestion  of  the  systemic  veins  may  exist  for  several 
years  but  gradually  leads  to  tricuspid  incompetency,  cyanotic 
induration  and  anasarca. 

Diagnosis.  The  first  symptom  noticed  is  shortness  of  breath 
on  exertion  or  on  going  up  stairs.  Disturbed  compensation  is 
marked  by  dyspnea,  cyanosis,  palpitation,  frequent  attacks  of  bron- 
chitis due  to  pulmonary  congestion,  hemoptysis,  and  persistent 
cough  with  blood-stained  sputum  containing  alveolar  cells  and 
pigmented  granules.  Cardiac  "sleep  start"  is  a  disturbing  feature 
— just  as  the  patient  falls  asleep,  he  wakes  gasping  for  breath  and 
feeling  as  if  the  heart  were  stopping.  There  may  be  a  sense  of 
emptiness  or  cardiac  distress,  the  pain  not  usually  being  severe. 
The  face  is  pale  and  pinched,  the  lips  and  ears  dusky,  the  cheek 
capillaries  are  enlarged,  the  fingers  are  clubbed,  especially  in 
children. 

In  a  child  or  in  older  persons  in  whom  the  lesion  has  dated 
from  childhood  there  is  often  visible  precordial  bulging.  The  apex 
beat  is  at  first  forcible,  diffuse  and  heaving;  as  compensation  fails 
it  becomes  feeble  or  unrecognizable;  it  is  displaced  to  the  sixth 
intercostal  space  to  the  left  of  nipple  line.  Thrill  is  rare.  The 
pulse  is  at  first  full,  regular,  small  and  soft  (low  tension).  After 
broken  compensation,  it  becomes  irregular,  no  two  beats  of  equal 
force  or  volume. 

The  area  of  cardiac  dullness  is  increased  transversely  and  ver- 
ticall}^.  A  blowing  murmur,  systolic  in  time,  heard  loudest  at 
apex,  propagated  to  axilla  and  under  the  angle  of  the  scapula, 
modifies  or  replaces  the  valve  sound.  If  the  murmur  is  loud  it 
may  be  heard  at  the  back  close  to  left  side  of  spine,  or  in  the  left 
axilla,  or  just  beneath  the  angle  of  the  left  scapula.    The  second 


164  THE  ENDOCARDIUM 

pulmonic  sound  is  markedly  accentuated  particularly  in  the  pul- 
monary area.    The  recumbent  position  makes  this  murmur  clearer. 

The  urine  is  scanty  and  albuminous,  with  tube  casts  and  some- 
times blood  corpuscles. 

The  sphygmogram  shows  a  wavy  irregular  line,  with  occasional 
normal  waves  among  irregular  waves  of  low  and  variable  ampli- 
tude. 

Prognosis.  No  ill  effects  result  as  long  as  compensation  can 
be  maintained.  There  are  apt  to  be  many  short  attacks  of  appar- 
ently failing  compensation,  from  which  the  patient  easily  recovers, 
with  rest  and  other  suitable  treatment  (q.  v.).  When  compensa- 
tion fails,  pulmonary  congestion  may  lead  to  death.  Pneumonia 
or  other  pulmonary  disease  is  apt  to  be  fatal,  at  any  time.  Dropsy 
or  exhaustion  may  be  the  immediate  cause  of  death.  Sudden  death 
is  less  frequent  than  in  other  valve  lesions. 


MITRAL  STENOSIS 

This  lesion  is  usually  associated  with  mitral  regurgitation. 
Hypertrophy  of  the  left  auricle  is  more  marked  than  in  regurgita- 
tion alone. 

Diagnosis.  During  compensation  (which  may  last  for  years) 
there  are  no  symptoms.  When  compensation  fails,  there  is  a  small, 
rapid,  irregular,  feeble  pulse,  dyspnea,  cough,  signs  of  pulmonary 
engorgement,  bronchorrhea,  frequently  hemoptysis,  followed  by 
dilatation  of  the  right  heart,  with  general  venous  stasis,  liver 
greatly  enlarged,  and  death. 

Any  time  during  the  duration  of  the  lesion,  vegetations  may 
loosen  and  enter  the  general  circulation.  If  these  emboli  reach 
the  brain,  aphasia,  hemiplegia,  or  other  symptoms  of  cerebral 
embolism  may  occur.  ♦ 

The  enlarged  auricle  may  press  upon  the  recurrent  laryngeal 
nerve  and  cause  paralysis  of  the  vocal  cord  of  the  same  side. 
During  hypertrophy  of  the  left  auricle  an  undulatory  impulse  is 
seen  over  its  area,  with  bulging  over  the  lower  part  of  the  sternum 
and  fifth  and  sixth  costal  cartilages.  This  is  most  marked  in  chil- 
dren. There  is  a  thrill  or  fremitus  rough  and  grating  in  quality, 
presystolic  in  time,  terminating  in  a  sharp  sudden  shock,  syn- 
chronous with  the  cardiac  impulse,  felt  best  during  expiration  and 
in  a  limited  area  to  the  left  of  the  sternum  in  fourth  and  fifth 
interspaces  within  the  nipple  line.  During  dilatation,  the  cardiac 
impulse  is  diffused,  feeble  and  irregular,  left  near  the  xiphoid  car- 
tilage. During  compensation,  the  pulse  is  slow,  regular,  small, 
and  of  good  tension.  If  the  orifice  is  much  narrowed,  it  is  small, 
weak,  and  irregular  in  Jorce  and  rhythm.  If  compensation  fails, 
and  the  right  heart  is  dilated,  it  is  rapid,  weak,  small  in  size  and 


AORTIC  REGURGITATION  165 

irregular  in  force  and  rhythm.  The  systemic  arterial  blood  pres- 
sure is  lowered  because  the  whole  volume  of  blood  cannot  be  sent 
out.  There  is  an  increased  area  of  cardiac  dullness  on  the  right 
side  of  sternum  and  along  left  margin  as  the  hypertrophy  is  on  the 
right  side.  It  may  even  extend  up  to  the  second  rib.  A  rough 
blowing  vibratory,  sometimes  rasping  or  purring  murmur,  high  in 
pitch,  is  heard  in  the  mitral  area,  to  the  inner  side  of  the  apex  beat 
or  along  the  left  sternal  margin,  presystolic  in  time,  running  up 
to  the  first  sound  in  which  it  abruptly  ends,  synchronous  with  the 
thrill.  The  first  sound  is  short  and  clear  and  abrupt.  The  second 
pulmonic  sound  is  accentuated.  In  the  later  stages,  when  the  nar- 
rowing becomes  considerable,  a  mid-diastolic  murmur  may  appear 
occupying  the  whole  of  diastole.  The  second  sound  may  disappear. 
As  compensation  fails,  the  murmur  may  disappear,  leaving  only 
a  flapping  or  snappy  first  sound  at  the  apex  of  a  gallop  rhythm. 
The  sphygmographic  tracing  is  an  irregular  line,  with  somewhat 
shorter  waves  than  in  regurgitation  alone.  Normal  ascents  and 
descents  are  less  frequent,  and  the  irregularity  is  more  marked 
than  in  the  first  lesion. 

Prognosis.  The  outlook  is  about  the  same  as  in  mitral  regurgi- 
tation. Cerebral  emboli  are  apt  to  occur.  Pregnancy  and  the 
puerperium  are  thought  to  be  detrimental,  but  many  women  go 
through  repeated  pregnancies  without  rupturing  compensation. 

AORTIC  REGURGITATION 

This  is  the  lesion  of  athletic  and  able-bodied,  vigorous  men,  and 
stands  next  in  frequency  to  mitral  regurgitation.  The  orifices  are 
more  or  less  dilated  resulting  in  the  non-closure  of  the  aortic 
valves,  allowing  a  part  of  the  blood  to  flow  back  into  the  left  ven- 
tricle. This  causes  overfilling  of  the  ventricle,  hence  dilatation  of 
its  cavity.  The  muscle  hypertrophies  to  compensate  which  may 
cause  the  heart  to  attain  an  enormous  size,  the  "cor  bovinum"  of 
the  old  writers. 

Diagnosis.  The  earliest  signs  are  due  to  cerebral  anemia,  head- 
ache, dizziness,  flashes  of  light,  feeling  of  faintness  on  sudden 
rising,  these  followed  by  congestion  of  the  face  and  eyes,  tinnitus 
aurium,  and  insomnia.  Precordial  pain  is  usually  present  and  may 
be  severe,  often  with  anginoid  attacks.  True  angina  pectoris  is 
more  often  associated  with  this  than  with  other  valvular  lesions. 
On  the  slightest  failure  of  compensation,  the  cardiac  action  be- 
comes excessive  and  distressing,  palpitation  on  slight  exertion 
causing  anxiety  and  fear  in  the  patient.  There  is  gradual  or  rapid 
appearance  of  dyspnea,  increased  on  exertion,  cyanosis,  hepatic 
enlargement,  renal  congestion  with  scanty,  albuminous  urine  and 
edema  of  the  feet.    Ascites  is  rare.     Mental  disturbances  are  fre- 


166  THB  ENDOCARDIUM 

quent.  Cases  of  neurasthenia  in  athletic  persons,  and  of  suicide 
during  apparently  vigorous  health,  are  more  often  due  to  this 
lesion  than  is  generally  recognized.  Syncope  is  frequent.  Sec- 
ondary anemia  may  be  marked;  the  red  count  may  be  lower  than 
3,000,000  per  cu.  mm.  • 

The  cardiac  impulse  is  forcible,  displaced  downward  and  to  the 
left,  pulsation  far  beyond  normal  apex  to  sixth  or  seventh  inter- 
space in  left  anterior  axillary  line  and  accompanied  by  a  charac- 
teristic jerking.  A  diastolic  thrill  may  be  felt  over  the  base  of  the 
heart  and  adjacent  to  the  large  vessels.  The  apex  beat  is  found 
in  the  seventh  or  eighth  interspace  in  anterior  axillary  line.  The 
pulse  is  rapid  and  characterized  by  a  sudden  rise  and  a  sudden 
fall  producing  a  peculiar  kicking  sensation  to  the  finger — "water- 
hammer"  or  Corrigan's  pulse.  There  may  be  retardation  of  the 
pulse  so  that  there  is  an  appreciable  interval  between  the  heart 
beat  and  the  radial  pulse.  The  sphygmographic  tracing  is  charac- 
terized by  sharply  rising  anacrotic  wave,  to  great  height;  the 
katacrotic  wtave  drops  with  a  needle  point;  the  dicrotic  is  very 
sharply  marked.  With  failing  compensation  or  the  development 
of  other  valve  lesions,  the  line  becomes  variably  irregular.  Capil- 
lary pulse  is  well-marked  in  the  finger  nails  or  in  the  lips  as  an 
alternate  flushing  and  paling.  Pulsation  in  peripheral  vessels  is 
more  common  in  this  than  in  other  forms. 

There  is  increase  of  cardiac  dullness  downward  and  to  the  left, 
occasionally  upward  and  to  the  left  of  the  sternum  from  hyper- 
trophy of  the  left  auricle,  and  associated  with  massive  hypertrophy. 
A  soft  blowing  prolonged  murmur,  of  low^  pitch,  and  a  churning 
or  rushing  character,  is  heard  in  the  aortic  area,  most  distinct  at 
junction  of  sternum  and  fourth  left  costal  cartilage,  diastolic  in 
time,  and  transmitted  down  the  sternum  and  toward  the  apex. 
It  may  modify  or  replace  the  second  sound  which  is  usually  absent. 
Auscultation  over  the  carotid  artery  may  reveal  the  second  sound 
when  it  is  not  found  at  the  aortic  cartilage.  This  indicates  a  small 
amount  of  regurgitation,  hence  a  better  prognosis.  Double  mur- 
murs may  be  heard  on  auscultation  over  the  carotids  and  sub- 
clavians. 

The  persistent  and  uniformly  high  systolic  blood  pressure  with 
the  low  diastolic  pressure,  gives  high  pulse  pressure;  this  is 
pathognomonic. 

AORTIC  STENOSIS 

This  is  chiefly  a  disease  of  advanced  life,  associated  with  arterio- 
sclerosis. There  is  usually  simply  a  slow  sclerotic  change  in  the 
valves,  usually  with  some  regurgitation.  Hypertrophy  of  the  left 
ventricle  follows  the  gradually  diminishing  orifice. 

Diagnosis.  There  are  no  noticeable  symptoms  as  long  as  the 
hypertrophy  keeps  pace  with  the  stenosis.    Later,  syncope,  vertigo. 


TRICUSPID  REGURGITATION  167 

headache  and  insomnia  or  bad  dreams  occur.  Anemia  is  present; 
emboli  may  lead  to  serious  complications.  The  apex  beat  is  slow, 
heaving,  forcible,  displaced  to  the  left  according  to  the  hyper- 
trophy. A  marked  thrill  at  the  base  of  the  heart  and  of  maximum 
force  in  the  aortic  area  is  felt.  In  no  other  condition  is  there  such 
an  intense  thrill.  The  pulse  is  small,  hard,  slow  (pulsus  tardus), 
often  interrupted,  and  the  tension  often  increased  depending  upon 
the  obstruction  and  degree  of  hypertrophy.  The  sphygmogram 
shows  a  blunt  ascent,  often  with  a  notch  near  the  summit;  a 
plateau  marks  the  height  of  the  anacrotic  wave.  The  katacrotic 
wave  descends  slowly,  and  the  dicrotic  wave  is  rarely  visible.  The 
base  line  may  be  prolonged.  The  area  of  dullness  is  never  as  wide 
as  in  aortic  regurgitation.  The  first  sound  is  replaced  by  a  harsh, 
loud,  rasping,  sometimes  whistling  or  often  musical  murmur, 
heard  best  in  the  aortic  area  at  junction  of  the  second  right  costal 
cartilage  with  the  sternum.  It  is  systolic  in  time,  and  transmitted 
into  the  carotids.  When  associated  with  aortic  regurgitation,  there 
is  a  double  or  see-saw  murmur.  There  are  other  murmurs  in  this 
area  not  due  to  stenosis;  the  hemic  murmur  has  a  soft  bruit;  cal- 
careous plates  in  the  aorta  or  on  a  cusp  produces  a  sound  very 
similar  to  the  stenotic  murmur. 

The  prognosis  is  comparatively  favorable,  as  hypertrophy  is 
usually  of  good  degree  and  easily  maintained  with  a  quiet  life. 
When  the  stenosis  is  solitary,  it  is  often  due  to  atheroma,  with 
danger  of  cerebral  hemorrhage. 

TRICUSPID  REGURGITATION 

The  general  symptoms  are  due  to  retarded  pulmonary  circula- 
tion and  visceral  congestion,  marked  as  follows :  In  the  lungs,  as 
dyspnea,  bronchitis,  or  pulmonary  edema ;  in  the  digestive  tract 
by  dyspepsia,  hematemesis,  ascites  and  slight  hepatic  enlargement, 
tenderness  and  icterus ;  in  the  kidneys  by  scanty  high-colored 
urine,  varying  amounts  of  albumin,  few  hyaline  casts,  isolated  red 
blood  cells  and  general  dropsy  and  uremia;  in  subcutaneous  tissues 
by  edema  beginning  in  the  feet  and  ankles  and  extending  upward, 
and  in  grave  cases  by  ascites,  hydropericardium  or  hydrothorax. 

Jugular  pulse-wave  is  observed  more  often  in  the  right  than  in 
the  left  vein.  The  cardiac  impulse  is  feeble  and  extends  down- 
ward. The  rhythmical  expansile  liver  pulsation  is  best  obtained 
by  laying  one  hand  over  the  fifth  and  sixth  costal  cartilages  and 
the  other  hand  over  the  lower  border  of  the  liver  in  the  mid- 
axillary  line.  The  jugular  vein,  when  obstructed  by  the  palpating 
finger,  fills  up  from  below  during  s}'stole.  There  is  hypertrophy 
of  the  right  ventricle.  A  soft  blowing  murmur,  low  in  pitch,  sys- 
tolic in  time,  is  heard  distinctly  over  the  xiphoid  cartilage,  or  the 
head  of  fourth  rib  to  right  of  sternum,  and  within  an  inch  of  the 


168  THB  ENDOCARDIUM 

apex,  thus  limiting  the  area  of  transmission.  The  second  pul- 
monary sound  is  weak.  There  may  be  either  a  single  or  a  double 
sound  in  the  crural  or  other  large  superficial  veins.  The  pulse  is 
markedly  irregular. 

The  prognosis  is  always  g^ave.  Each  case  must  be  considered 
on  its  own  merits. 

TRICUSPID  STENOSIS 

This  is  a  rare  congenital  or  acquired  affection  occurring  sec- 
ondary to  disease  of  the  left  heart  or  associated  with  acute  endo- 
carditis. Clinically,  cyanosis  of  the  face  and  lips  is  commonly 
seen,  this  becoming  pronounced  when  dropsy  occurs.  The  physical 
signs  are  transverse  enlargement  of  the  heart,  particularly  the 
right  side;  a  presystolic  murmur  heard  at  the  base  of  the  ensiform 
cartilage,  and  a  presystolic  thrill.  Dilatation  of  the  auricles  soon 
follows  with  venous  stasis,  and  venous  pulsations  as  in  tricuspid 
regurgitation,  with  which  it  is  usually  associated. 

The  prognosis  is  alw&ys  very  unfavorable;  death  is  usually 
imminent  when  the  diagnosis  is  made. 


THE  PULMONARY  VALVES 

Murmurs  heard  in  the  region  of  the  pulmonary  valves  are 
extremely  common,  but  lesions  of  the  valves  are  exceedingly  rare. 
It  is  often  called  the  "area  of  auscultatory  romance,"  of  Balfour. 

A  systolic  murmur  is  heard  in  healthy,  thin-chested  individ- 
uals, particularly  children,  during  expiration  and  in  the  recumbent 
position ;  with  rapid  heart  action  as  in  fevers  or  after  exertion ;  in 
most  anemic  states.  These  functional,  anemic,  or  hemic  murmurs 
are  always  at  the  base  of  the  heart;  always  systolic;  not  trans- 
mitted away  from  heart;  soft  in  character;  low  in  pitch;  variable 
in  intensity,  now  heard,  now  absent. 

PULMONARY  STENOSIS  is  the  commonest  of  the  congenital  mur- 
murs and  may  be  associated  with  constriction  of  the  pulmonary  artery;  patu- 
lous foramen  ovale;  patulous  ductus  Botalli  or  its  stricture;  imperfection  of 
the  ventricular  septum. 

Hypertrophy  of  the  right  ventricle  may  follow  and  .establish  compensation. 
The  child  is  weak,  markedly  cyanosed,  with  flabby  tissues,  soft  bones,  and  a 
generally  poorly  nourished  condition.  The  physical  signs  are  marked  enlarge- 
ment of  the  right  ventricle,- a  loud  systolic  murmur  with  a  thrill  heard  best  to 
left  of  sternum  in  the  second  interspace  and  not  transmitted  to  the  vessels. 
The  second  pulmonic  sound  is  weak  or  absent  or  replaced  by  a  diastolic  mur- 
mur. 

The  prognosis  is  unfavorable,  the  little  patients  dying  in  a  fe\v  days  to  a  few 
months.  Sometimes,  compensation  is  established  so  that  they  live  longer  but 
they  are  always  weakly. 

PULMONARY  REGURGITATION  is  a  rare  affection  usually  of  con- 
genital malformation;  the  changes  are  similar  to  those  of  aortic  insufficiency. 


VALVULAR  LESIONS  169 

The  general  symptoms  are  referable  to  dilatation  of  the  right  heart  and  conse- 
quent pulmonary  congestion.  Suffocative  attacks  are  marked.  On  examination, 
the  cardiac  dullness  extends  to  the  right  of  the  sternum,  a  loud  blowing  diastolic 
murmur  is  heard  most  distinctly  at  the  junction  of  the  third  left  costal  cartilage 
and  the  sternum,  transmitted  down  the  sternum.  Death  occurs  from  dropsy 
and  exhaustion. 

Treatment  of  Valvular  Lesions.  Functional  recovery  is  to  be 
expected — this  is  due  to  compensatory  hypertrophy  of  the  myo- 
cardium. This  is  to  be  secured  only  when  the  conditions  which 
control  the  action  of  the  heart  are  normal — or  approximately  so. 
Modification  of  the  heart's  rate  and  force  to  meet  varying  physio- 
logical states  depends  upon  normal  activity  of  the  cardiac  nerve 
centers  and  upon  the  maintenance  of  fairly  normal  blood  and  blood 
pressure.  In  order  that  the  most  speedy  and  perfect  compensation 
can  be  secured,  all  factors  that  might  interfere  with  the  normal 
activities  of  the  heart  centers  must  be  removed.  This  includes 
lesions  of  the  upper  thoracic  and  cervical  spine,  the  clavicles,  and 
the  upper  ribs;  all  factors  which  raise  the  blood  pressure  unduly 
must  be  removed;  this  includes  lesions  of  the  lower  thoracic  spine, 
especially;  all  strenuous  exercise,  all  emotional  storms  and  all 
causes  of  gastric  disturbances  or  flatulence.  All  factors  which 
diminish  the  nutritive  qualities  of  the  blood,  or  which  add  to  its 
toxic  elements,  must  be  removed.  This  includes  the  use  of  alcohol 
or  tobacco,  the  overuse  of  meats  and  carbohydrates,  any  dietetic 
errors,  constipation,  and  lesions  which  might  interfere  with  the 
activities  of  skin,  kidneys,  lungs,  liver,  or  any  other  of  the  organs 
concerned  in  nutrition  or  elimination.  Relief  may  be  given  by  rais- 
ing the  lower  ribs  and  elevating  the  abdominal  viscera.  Forced 
expiration,  with  contraction  of  the  diaphragm,  may  give  relief. 

In  case  of  pain  or  sudden  dilatation. with  cyanosis,  cold  locally 
over  the  heart  is  indicated,  such  as  an  ice  bag,  Leiter's  coil,  or  com- 
presses kept  cold.  Insomnia  is  often  relieved  by  a  cup  of  hot  gruel 
or  a  tepid  bath  at  bed  time.  Massage  to  limbs  at  bed  time  may 
encourage  sleep.  The  condition  of  the  heart  and  respiration  must 
be  noted,  and  the  blood  pressure  variations  watched  constantly  at 
first;  each  patient  presents  more  or  less  peculiar  idiosyncrasies. 

"In  giving  a  summation  of  the  osteopathic  treatment  for  heart  conditions 
in  general  we  must  aim  to  reduce  the  work  of  the  heart  to  the  minimum. 
The  disturbed  circulation  must  be  controlled  by  careful  attention  to  the  vaso- 
motor nerves  at  the  various  centers  along  the  spine.  Treatment  must  be  given 
to  correct  any  lesion  found  in  the  ribs  or  vertebrae  from  the  first  to  the  tenth 
dorsal.  See  that  the  tenth  cranial  nerves  are  not  obstructed  anywhere  along 
their  course.  The  ribs  must  be  spread,  the  sternum  raised  and  the  chest 
expanded  to  the  utmost  to  give  the  lungs  free  action.  The  importance  of  the 
lung  is  often  overlooked  in  the  treatment  of  heart  troubles.  We  must  obtain 
the  maximum  amount  of  oxygen  to  nourish  the  blood.  Relax  the  musajes  all 
along  the  line.  Remove  the  lesions  of  the  cervical  area,  and  free  up  the  cervical 
ganglia  of  the  sympathetic  chain.  A  general  treatment  to  quiet  the  patient  may 
be  indicated.  Remember  the  possibility  of  a  reflex  irritation  at  some  remote 
point.    The  excretory  organs  must  be  kept  active  and  a  proper  diet  ordered. 


170  ^         THE  ENDOCARDIUM 

"It  is  difficult  to  outline  with  exactness  the  treatment  for  a  given  heart 
lesion  on  account  of  the  varied  causes  that  may  contribute  to  the  condition. 
In  general,  look  for  all  the  causes  and  remove  them  as  far  as  possible.  Try 
to  lessen  the  work  of  the  heart  and  aim  to  build  up  compensation  by  giving  the 
heart  good  nourishment  for  its  work." — L.  J.  Bingham^ 

"The  existence  of  the  lesions  as  found  is  held  to  interfere  with  the  progress 
of  the  compensatory  hypertrophy. 

"The  treatment  of  these  cases  includes  the  correction  of  whatever  bony 
lesions  are  found  which  might  interfere,  (a)  with  the  innervation  of  the  heart, 
(b)  with  the  nutrition  of  the  body,  (c)  with  the  maintenance  of  a  normal 
blood  pressure.  The  correction  of  any  abnormal  habits  of  eating,  sleeping, 
resting,  etc.,  which  may  be  present  is  held  to  be  an  important  part  of  the  osteo- 
pathic treatment,  as  is  also  the  cessation  of  whatever  drugs  the  patient  may 
have  been  using.  Usually  the  drugs  are  stopped  at  once,  but  sometimes,  when 
the  patient  is  very. weak  and  nervous,  the  drug-habit  is  stopped  gradually.  In 
every  case  recorded  the  drug  has  been  discontinued  within  the  week." — P.  C. 
O.  Clinic  Report. 

"The  treatment  of  valvular  lesions  in  general  and  mitral  lesions  in  par- 
ticular, is  not  confined  to  the  lesions  at  the  valves,  but  concerns  the  resulting 
complications.  The  s3Tnptoms  of  cardiac  lesions  do  not  manifest  themselves 
until  the  heart  muscle  is  worn  out,  when  compensation  is  lost.    .    .    . 

"The  fact  that  most  cases  recover  compensation  under  proper  treatment 
and  the  heart  muscle  is  able  to  do  its  work  fairly  well,  even  after  it  had  been 
apparently  completely  exhausted,  is  evidence  that  the  weakness  was  not  due 
to  degeneration,  but  to  fatigue.  .  .  .  First,  we  must  have  absolute  rest  in 
bed  to  relieve  the  heart  of  all  unnecessary  labor;  second,  daily  osteopathic 
treatment  practically  the  whole  length  of  the  spine;  in  the  cervical  and  upper 
dorsal  regions  to  improve  the  tone  of  the  cardiac  muscle  and  the  tone  of  the 
peripheral  arterioles;  in  the  middle  dorsal,  for  a  tonic  effect  upon  the  lung 
tissues  and  the  great  splanchnics,  and  to  increase  the  action  of  the  sweat 
glands ;  in  the  lower  dorsal,  for  a  diuretic  effect  upon  the  kidneys ;  in  the 
lumbar  region,  for  the  bowels.     .     .     . 

"The  diet  should  be  confined  to  milk  and  milk  products,  both  for  nourish- 
ment and  for  its  diuretic  effect.  .  .  .  After  compensation  has  been  success- 
fully reestablished,  the  patient  should  be  kept  under  observation  for  at  least 
a  year,  and  the  same  hj'gienic  and  dietetic  rules  laid  down  for  the  stage  of  com- 
pensation must  be  strictly  adhered  to." — C.  J.  Muttart. 

The  prognosis  of  any  cardiac  valve  lesion  depends  upon  the 
efficiency  of  compensation.  This  in  turn  is  dependent  upon  several 
factors.  In  children  under  ten  years,  the  outlook  is  grave,  although 
sudden  death  is  rare.  Lesions  acquired  during-  puberty  are  more 
apt  to  be  permanently  compensated.  Women  bear  valvular  dis- 
ease better  than  men. 

To  justify  a  favorable  prognosis,  several  factors  must  be  pres- 
ent ;  a  good  general  health,  good  habits,  the  existence  of  no  excep- 
tional liability  to  rheumatism  or  catarrh,  that  the  origin  of  the 
valve  lesion  is  independent  of  the  degenerations,  the  existence  of 
the  valve  lesion  without  any  change  for  over  three  years,  the  ven- 
tricles acting  with  moderate  frequency  and  general  regularity,  the 
presence  of  sound  arteries,  and  freedom  from  pulmonary,  hepatic, 
or  renal  congestion. 


CHAPTER  XVII 
DISEASES  OF  THE  BLOOD  VESSELS 

GENERAL  DISCUSSION 

The  lining  of  the  arteries,  veins  and  heart  is  continuous  and- 
practically  identical.  Through  this  channel,  with  its  lining  mem- 
brane of  a  single  layer  of  endothelial  cells  the  blood  flows  with 
constantly  varying  pressure  and  carrying  varying  combinations  of 
food  and  of  waste  materials. 

The  walls  of  the  blood  vessels  are  nourished  by  the  vaso-vas- 
orum ;  these  are  controlled  by  vasomotor  nerves,  as  are  other  tis- 
sues of  the  body.  The  muscular  walls  of  the  vessels  are  also 
controlled  by  nerves  which  vary  their  caliber.  Both  these  sets  of 
nerves  carry  impulses  from  nerve  centers;  these,  like  other  nerve 
centers,  are  influenced  by  the  impulses  reaching  them  over  sensory 
nerves,  and  from  related  centers  in  other  parts  of  the  nervous 
system.  Thus,  bony  lesions  affect  the  nutrition  and  the  functional 
activities  of  the  vascular  walls.  The  blood  vessels  are  nourished 
by  the  blood,  as  are  all  other  tissues  of  the  body.  Thus,  they  are 
subject  to  the  toxic  and  nutritional  variations  in  the  blood.  They 
carry  the  blood  under  pressure,  and  so  are  liable  to  injury  from 
improper  changes  in  this  pressure.  These  three  factors — variations 
in  nervous  control,  variations  in  the  quality  of  the  blood,  and 
variations  in  the  pressure  of  the  blood,  are  the  factors  which 
make  up  the  etiology  of  diseases  of  the  blood  vessels  and  which 
also  determine  the  methods  most  efficient  in  securing  recovery 
from  these  conditions. 

The  practical  aspect  of  this  question  is  of  great  importance.  In 
the  first  place,  the  etiological  value  of  the  bony  lesion  in  causing 
disturbances  in  the  pressure  of  the  blood  must  be  recognized. 
Slight  malpositions  of  vertebrae  and  ribs,  or  other  forms  of  periph- 
eral irritation  anywhere,  may  affect  the  chief  vasomotor  centers, 
or  the  subsidiary  centers  in  the  cord  or  medulla.  If,  as  the  result 
of  these  lesions,  or  of  other  factors,  the  blood  pressure  falls  too 
low,  the  nutrition  of  the  entire  body  may  be  affected;  this  mal- 
nutrition, with  the  associated  accumulation  of  more  or  less  toxic 
waste  products  of  metabolism,  predisposes  to  vascular  disease  no 
less  than  does  the  abnormally  high  blood  pressure  which  may  be 
due  to  bony  lesions  as  well  as  to  the  causes  given  for  arterio- 
sclerosis in  general. 

The  treatment  of  diseases  of  the  blood  vessels  depends  upon 
the  removal  of  these  factors — those  which  interfere  with  normal 

171 


172      ."  THB  BLOOD  VESSELS 

nervous  control;  those  which  interfere  with  the  normal  pressure 
or  the  normal  flow  of  the  blood,  and  those  which  interfere  with 
the  normal  quality  of  the  blood  in  the  vessels.       ^ 


ARTERIOSCLEROSIS 

(Arterio-capillary  fibrosis;  atheroma;  endarteritis  chronica  deformans;  arterial 

sclerosis) 

Arteriosclerosis  is  a  rigid  condition  of  the  arteries  produced 
by  fibrous  thickening  of  their  walls;  it  is  associated  with  fibrous 
changes  in  other  organs  and  is  marked  clinically  by  hypertension 
and  functional  disturbances  dependent  upon  the  location  and  extent 
of  the  fibrosis. 

Etiology.  The  hardening  of  the  connective  tissues,  especially 
of  the  arteries,  in  old  age  is  so  constantly  observed  in  man  and 
the  higher  animals,  that  it  may  be  considered  a  factor  in  normal 
living.  Among  the  factors  producing  this  hardening  prematurely, 
may  be  included  heredity;  poisons  such  as  lead,  mercury,  alcohol, 
drugs ;  syphilis,  nephritis,  malaria,  rheumatism,  gout,  diabetes,  and 
other  diseases  with  toxic  characters ;  the  products  of  intestinal 
putrefaction  and  fermentation,  especially  indol  and  related  sub- 
stances; and  the  continued  high  blood  pressure  due  to  overeating 
and  drinking,  excitement,  worry,  too  great  and  frequent  muscular 
effort,  etc.  It  is  seen  that  these  causes  fall  into  two  groups — the 
toxic  and  the  mechanical. 

The  spinal  column  is  invariably  rigid,  especially  in  the  lower 
thoracic  region.  This  abnormal  rigidity  may  be  due  in  part  to 
the  hardening  and  rigidity  of  all  tissues  not  kept  supple  by  use, 
but  it  is  certainly  an  important  causative  factor.  Rigid  thorax 
is  common.  Lateral  curves  are  less  frequent  than  slightly  pos- 
terior positions,  or  the  "ramrod"  spine. 

"Where  the  sclerosis  has  attacked  the  upper  limbs,  the  most  frequent  lesions 
have  been  from  the  third  to  the  fifth  dorsal  vertebrae,  and  as  has  been  the  case 
of  an  unequal  blood  pressure,  the  lesions  were  rotations  of  those  vertebrae.  In 
two  incidents,  bi-lateral  sclerosis  of  the  radials  existed  without  apparent  involve- 
ment of  other  palpable  arteries.  The  lesion  was  of  an  impacted  anterior  nature 
extending  from  the  second  to  fifth  dorsal. 

"Cases  exhibiting  unequal  tortuosity  of  the  facial  and  temporal  arteries,  in 
my  experience,  have  invariably  shown  lesions  of  the  second,  third  and  fourth 
cervical  vertebrae  and  likewise,  invariably  these  have  been  rotations  toward  the 
sclerosed  side. 

"There  is  another  type  of  sclerosis  common  to  osteopathic  practice,  the 
etiology  of  which  is  apparently  auto-intoxication." — F.  C.  Farmer. 

Pathology.  The  aorta  is  first  in  frequency  of  disease,  next  come  the 
coronary  arteries.  The  cerebral,  temporal,  radial,  brachial,  ulnar,  femoral  are 
found  affected  in  the  order  named.  The  change  seems  to  begin  in  the  intima, 
with  slightly  raised  thickenings,  due  to  multiplication  of  the  endothelial  cells. 
This  condition  is  called  "atheroma"  or  "gruel-tumor"  on  account  of  its  con- 
sistency.   The  media  and  adventitia  undergo  inflammatory,  changes  as  a  result 


ARTERIOSCLBROSIS  173 

of  the  pressure  or  toxins,  muscle  fibers  are  absorbed,  and  the  connective  tissue 
overgrowth  results  in  the  formation  of  thick,  weak,  inelastic  walls.  The  atheroma 
may  soften  and  the  wall  of  the  vessel  become  perforated,  or  may  dilate  greatly, 
with  the  formation  of  an  aneurysm.  Calcification  may  occur  in  the  areas 
affected  most  by  the  disturbed  circulation. 

Diagnosis.  The  symptoms  are  hypertension  of  the  pulse, 
hypertrophy  of  the  left  ventricle,  accentuation  of  the  second 
sound  in  the  aortic  area,  and  thickening  of  the  peripheral  ves- 
sels. Early  there  may  be  a  prolonged  first  sound.  The  arterial 
w*alls  are  palpated  by  obliterating  the  pulse  when  they  appear 
like  cords  under  the  finger.  Sometimes  irregular  thickenings  or 
the  edges  of  calcareous  plates  in  the  walls  can  be  palpated.  Arterio- 
sclerosis may  be  advanced  in  the  aorta  and  other  great  vessels 
without  symptoms.  Later  stages  are  marked  by  rigidity,  visibility, 
and  tortuosity  of  the  peripheral  arteries.  When  the  heart  is  fail- 
ing, the  sounds  are  feeble,  often  irregular  and  intermittent.  Among 
the  general  symptoms  of  arteriosclerosis  are  periods  of  mental  las- 
situde, irritability  with  headache  occurring  after  mental  or  physical 
excitement,  digestive  disturbance,  momentary  attacks  of  dizziness 
accompanied  by  nausea  and  followed  by  profuse  sweating  and 
temporary  weakness.  Insomnia,  loss  of  memory,  melancholia,  fear, 
show  gradual  loss  of  mental  vigor  and  bodily  tone. 

Sclerosis  of  the  renal  arteries  produces  urinary  changes  and 
the  arteriosclerotic  kidney,  sometimes  chronic  interstitial  nephritis. 
When  the  cerebral  arteries  are  involved,  there  may  be  transient 
attacks  of  hemiplegia  or  monoplegia  or  aphasia  with  recovery 
within  twenty-four  hours  and  recurrences  later ;  aneurysm,  rupture 
or  thrombosis  with  their  attendant  phenomena.  Sclerosis  of  the 
coronary  arteries  is  a  factor  in  producing  narrowing,  thrombosis, 
angina  pectoris,  or  aneurysm  of  the  heart.  When  the  arteries  of 
the  extremities  are  affected  thrombosis  and  senile  gangrene  or 
intermittent  claudication  or  lameness  (crural  angina)  may  occur. 

Urinary  changes  are  characteristic.  There  is  intermittent  albu- 
minuria, urea  and  nitrogen  are  normal,  uric  acid  is  low,  xanthin 
bases  are  increased,  sediment  is  scanty  and  hard  to  find,  casts  are 
rare,  and  uric  acid  and  calcium  oxalate  crystals  are  common. 

The  blood  pressure  is  increased.  There  may  be  only  a  constant 
slight  raise  of  20  to  30  mm.  of  Hg.  above  normal  or  it  may  run 
high ;  160  to  180  mm.  of  Hg.  is  Faught's  average. 

Treatment.  Increasing  the  mobility  of  the  dorsal  spine  and 
of  the  chest  with  elevation  of  the  ribs  is  indicated.  Whatever 
luxations  are  present  should  be  corrected.  Elimination  by  every 
avenue  is  to  be  stimulated.  Renal  efficiency  is  to  be  maintained 
by  careful  work  on  the  renal  splanchnics,  diet,  and  hygienic  regula- 
tions. Direct  abdominal  work  assists  in  equalizing  the  circulation 
and  lowers  the  blood  pressure. 


174  THE  BLOOD  VESSELS 

"Judgment  must  be  used  in  attempting  to  correct  faulty  blood  pressure  as 
well  as  other  conditions.  Relaxing  treatment  must  not  be  adopted  merely  on 
the  strength  of  sphygmomanometer  readings;  a  thick  vessel  with  a  cornpara- 
tively  low  reading,  say  135,  may  require  to  have  its  tone  raised,  while  a  thinner- 
walled  vessel,  with  a  reading  of  125,  may  advantageously  have  its  tone  lowered. 

"The  chief  difficulty,  it  seems  to  me,  is  that  most  people  confuse  arterio- 
sclerosis with  high  manometric  readings.  A  manometer  measures  the  resistance 
of  an  artery  to  outside  pressure,  which  is  often  due  to  hypertonicity  of  the 
vessel,  itself  in  turn  due  to  some  form  of  autointoxication.  The  high  reading 
is  not  necessarily  due  to  arterio-sclerosis." — C.  M.  Bancroft. 

The  corrective  movements  indicated  in  these  cases  should  be 
given  slowly  and  gently.  No  increased  sensory  stimulation  should 
be  sent  into  the  centers  from  the  articular  surfaces.  The  lesions 
must  be  corrected  without  stimulating  the  nerve  centers.  Direc- 
tions as  to  hygienic  measures  must  be  given  with  due  regard  to 
the  pressure  changes  liable  to  occur.  With  care,  the  blood  pres- 
sure may  be  kept  within  reasonable  limits  even  while  considerable 
corrective  work  is  being  done.  Careful  watching  of  the  pulse  may 
prevent  undue  rise  of  blood  pressure  in  the  aged  and  arterio- 
sclerotic. The  same  considerations  are  important  in  outlining  the 
treatment  and  the  hygienic  advice  for  patients  with  cardiac  lesions, 
aneurysms,  and  all  conditions  in  which  a  rise  of  blood  pressure  is 
harmful  or  dangerous. 

An  exclusive  milk  diet  is  often  of  service  in  reducing  a  dan- 
gerous hypertension.  Loss  of  strength  is  to  be  avoided.  In  obese 
cases  reduction  of  weight  must  be  gradual.  Fruit  and  vegetables 
with  the  milk  products  should  be  freely  used.  Meat  and  starch 
are  to  be  kept  low.  Sodium  chloride,  sprees,  tobacco,  alcoholic 
drinks,  are  to  be  omitted  or  greatly  moderated.  If  any  particular 
food  advised  is  found  to  cause  renal  irritation  it  must  be  stopped. 
A  water  intake  of  about  1500  cc. — 3  pints — is  best  in  most  cases. 

A  quiet  life  is  best,  but  Ihe  patient  must  not  be  unhappy. 
Baths  must  not  be  of  extreme  temperatures  either  hot  or  cold. 
Warm  baths  and  sponging  daily  are  of  the  best  use.  Exercise 
should  be  taken  regularly,  moderate  out-door  sorts  being  best. 
Too  sudden  changes  in  altitude  are  not  advisable,  nor  residence 
above  3,000  feet  suitable.    An  even  climate  is  desirable. 

Prognosis.  Structural  changes  can  be  prevented  but  not 
removed.  If  the  case  is  recognized  early  before  renal  changes  are 
apparent,  diet,  hygiene,  and  a  general  low^er  plane  of  living  insti- 
tuted, the  promise  of  a  comfortable  life  for  many  years  may  be 
made.  The  condition  is  not  favorable  for  recovery  but  not  incom- 
patible with  life.  In  the  later  stages,  some  circulatory  accident  is 
apt  to  occur  on  slight  provocation.  These  include  apoplexy  and 
sudden  death. 

PHLEBOSCLEROSIS 

(Sclerosis  of  the  veins)  ^ 

This  condition  may  accompany  arterio-sclerosis,  hepatic  sclerosis,  or  mitral 
lesions.    The  pathology  and  treatment  are  those  of  arterio-sclerosis.     It  is  not 


ANEURYSM  175 

often    diagnosed    ante-mortem.     The   treatment  consists    in   relieving   the  high 

venous  blood  pressure  and  usually  in  the  increased  elimination  of  toxic  sub- 
stances from  the  blood  stream. 


ANEURYSM 

An  aneurysm  is  a  persistent  localized  dilatation  of  an  artery. 
It  may  be  fusiform,  saccular  or  cylindrical  in  form ;  it  is  called 
axial  when  the  entire  circumference  of  the  artery  is  affected ; 
peripheral  when  only  one  side  forms  the  sac.  Miliary  aneurysms 
are  so  called  from  their  small  size;  they  are  found  on  the  cerebral 
arteries.  A  false  aneurysm  is  produced  when  rupture  of  the 
arterial  coat,  usually  very  small,  permits  the  blood  to  escape  into 
the  perivascular  tissues.  The  connective  tissues,  with  the  coagula- 
tion of  the  blood  and  the  organization  of  this  clot,  form  a  sac 
which  may  become  very  strong.  A  dissecting  aneurysm  is  formed 
when  the  blood  penetrates  into  space  between  the  arterial  coats, 
separating  them.  This  blood  may  coagulate  and  organize  with 
no  further  harm.  Aneurysmal  varix  is  formed  when  an  arterio- 
venous connection  is  made  through  the  rupture  of  .weakened 
arterial  wall  into  an  adjacent  vein.  When  this  connection  is  made 
through  an  intervening  sac,  the  structure  is  called  a  varicose 
aneurysm. 

Etiology.  There  are  two  main  causes;  damage  to  the  vessel 
wall  from  arteriosclerosis  particularly  when  of  syphilitic  origin, 
or  from  causes  acting  from  without  the  vessel;  and  increased 
vascular  strain  as  a  result  of  laborious  occupations.  Among  the 
more  general  causes  are  toxemias  and  conditions  affecting  the 
innervation  of  the  vessels  from  spinal  or  other  subluxations.  It 
is  a  disease  especially  frequent  in  middle  life. 

Diagnosis.  In  terminal  arteries,  serious  symptoms  may  be 
produced  by  aneurysm  even  of  small  vessels;  otherwise  no  recog- 
nizable symptoms  are  apt  to  follow  unless  the  affected  vessel  is  an 
arterial  trunk.  Tumor,  pulsation,  systolic  murmurs  audible  over 
the  dilatation,  pain,  pressure  symptoms,  and  the  results  of  the 
impaired  circulation  are  the  symptoms  most  commonly  present. 
Other  symptoms  occur,  according  to  the  location  of  the  aneurysm. 
The  X-ray  gives  accurate  information  concerning  thoracic  aneu- 
rysm. 

Aneurysm  of  the  Aortic  Arch.  This  is  the  most  common  form. 
The  onset  is  gradual  with  arteriosclerosis  and  generally  failing 
health.  Pain,  dyspnea  and  cough  may  vary  in  degree  and  be 
either  constant  or  intermittent.  The  tumor  may  produce  visible 
bulging  with  pulsation.  Corrigan's  sign — expansile  pulsation — 
with  thrill  and  diastolic  shock,  tracheal  tugging,  and  tenderness 
oyer  the  affected  area,  may  be  found.    When  the  aneurysm  is  in 


176  THE  BLOOD  VESSELS 

the  transverse  arch  or  in  the  subclavian  artery  the  pulse  and  blood 
pressure  vary  in  the  right  and  left  carotid  or  radial  arteries. 

The  abnormal  area  of  dullness  with  increased  resistance  is 
often  evident.  Over  the  tumor  there  is  a  murmur  or  bruit  syn- 
chronous with  the  first  sound,  louder  than  systole,  lower  in  pitch, 
and  of  a  blowing  character.  When  the  aortic  valves  are  intact, 
the  aortic  spund  will  be  markedly  accentuated. 

Thoracic  Aorta.  This  is  most  frequent  among  men  who  are 
prematurely  aged  or  engaged  in  occupations  which  tend  to  increase 
normal  aortic  strain ;  syphilis  is  the  most  constant  factor  and  septic 
emboli  and  traumatism  are  worthy  of  mention.  The  symptoms 
are  due  to  pressure,  and  depend  upon  the  direction  of  protrusion. 
They  may  include  dysphagia;  dyspnea,  "aneurysmal  asthma"; 
alterations  of  the  voice,  as  stridor,  aphonia,  "leopard  growl,"  "goose 
cough,"  "gander  cough" ;  hemoptysis ;  severe  hiccough ;  dilatation 
or  contraction  of  the  pupils,  unilateral  or  bilateral ;  pallor  or  flush- 
ing of  the  face,  unilateral  or  bilateral ;  cardiac  irregularity ;  vomit- 
ing, nausea ;  edema  of  the  arms  and  face,  sometimes  unilateral ; 
and  other  symptoms  due  to  pressure  upon  nerves  or  vessels.  When 
the  thoracic  duct  is  involved  fatty  stools  and  rapid  emaciation 
may  veil  the  diagnosis.  Erosion  of  the  bodies  of  the  vertebrae  and 
pressure  upon  the  cord  cause  severe  boring  pain,  followed  by 
paraplegia  and  death. 

The  expansile  pulsation,  systolic  thrill  and  diastolic  shock  are 
found  above  the  third  costal  cartilage.  Tracheal  tugging  may  be 
present.  Percussion  adds  a  dull  flat  note  over  the  tumor  with 
increased  resistance.     The  apex  beat  is  displaced. 

Sometimes  differences  are  found  in  the  radial  pulses  or  the 
pulse  may  be  retarded  in  the  vessels  beyond  the  aneurysm. 

Over  the  dull  area  a  ringing  accentuated  second  sound  and  a 
systolic  bruit  are  characteristic. 

Descending  Thoracic  Aorta.  When  beyond  the  arch,  aneurysm 
is  often  latent.  In  other  cases,  there  is  pain  in  the  back  from 
erosion  of  the  vertebrae,  sometimes  dysphagia,  and  occasionally  a 
pulsatile  tumor  is  found  to  the  left  of  the  spine. 

Abdominal  Aorta.  This  occurs  most  commonly  near  the  coeliac 
axis;  it  may  grow  upward  and  push  the  diaphragm  before  it,  or 
backward  and  erode  the  vertebrae.  Characteristic  dull  boring  pain 
and  neuralgias  are  thus  produced. 

Palpation  reveals  a  definite  tumor  with  aneurysmal  character- 
istics. The  bruit  is  heard  to  the  left  of  the  median  line  and  the 
femoral  pulse  is  retarded.  Compression  paraplegia,  embolism  of 
the  superior  mesenteric  artery,  complete  obliteration  of  the  lumen 
or  rupture  lead  to  death.  Diagnosis  of  aneurysms  must  be  made 
from  mediastinal  tumors,  pulsating  emphysema  necessitatis,  aortic 


ANEURYSM  177 

insufficiency,  cardiac  displacements  by  other  thoracic  conditions, 
neurotic  pulsation  of  the  aorta,  and  abdominal  tumors. 

Aneurysm  of  the  Pulmonary  Artery  is  rarely  diagnosed  from 
thoracic  aneurysm.  It  is  rare,  and  is  caused  by  phthisis,  mitral 
disease,  emphysema,  or  other  causes  of  obstruction  to  the  pul- 
monary circulation. 

Aneurysm  of  the  Splenic  Artery  is  rarely  recognized.  The 
symptoms  include  deep-seated  abdominal  pain,  hematemesis, 
sometimes  hepatic  disturbances.  A  pulsating  tumor  with  systolic 
murmur,  may  lead  to  a  diagnosis.    Gastric  ulcer  or  gastric  cancer 

may  be  confused  with  this  aneurysm. 

Aneurysm  of  the  Hepatic  Artery  is  very  rare.  Severe  pain, 
vomiting,  hematemesis  and  jaundice  are  present. 

Aneurysm  of  the  Mesenteric  Arteries  cause  pain  and  vague 
intestinal  disturbances.  They  are  apt  to  rupture  into  the  peri- 
toneal cavity,  causing  sudden  death.  Ante-mortem  diagnosis  is 
practically  impossible. 

Miliary  Aneurysms  of  the  Renal  and  the  Cerebral  Vessels  are 

not  infrequent.  They  may  produce  no  symptoms,  or  various  vague 
pressure  symptoms. 

The  Treatment  of  Aneurysm  depends  largely  upon  the  location. 
Every  manipulation  must  be  very  carefully  considered  as  there  is 
no  way  of  estimating  the  strength  of  the  aneurysmal  wall.  Relax- 
ation of  the  contracted  spinal  muscles,  and  very  careful  treatment 
to  tone  up  the  general  nutrition,  secure  elimination  and  quiet  the 
circulation  are  some  of  the  measures  necessary.  Absolute  rest  of 
body  and  mind  is  essential  when  the  tumor  is  marked.  The  diet 
must  be  nourishing  but  limited  and  the  liquids  reduced  to  a 
minimum.    Alcohol  and  its  allies  are  strictly  prohibited. 

Rest  in  bed,  ice  over  the  affected  area,  long,  steady  pressure 
over  the  tissues  near  the  tenth  to  the  twelfth  thoracic  spines  may 
relieve  the  pain  and  lower  the  blood  pressure.  The  symptoms 
are  to  be  treated  as  they  occur;  much  relief  can  often  be  secured 
by  careful  treatment  according  to  the  spinal  conditions  as  found 
on  examination  each  day. 

If  the  blood  pressure  can  be  kept  rather  low,  the  coagulation 
of  the  blood  is  hastened  and  the  danger  of  embolism  lessened.  The 
restoration  of  normal  nerve  stimulation  to  the  injured  arterial 
walls  may  cause  increased  tone  and  a  tendency  to  recovery.  This 
is  best  secured  by  spinal  treatment. 

Very  low  liquid  intake  lowers  the  blood  volume  and  increases 
its  viscidity.  The  free  use  of  gelatine  is  supposed  to  increase  the 
coagulation  of  the  blood.  The  "pressure  treatment"  of  abdominal 
aneurysm  has  been  of  value  in  selected  cases;  steady,  increasing 
pressure  over  the  proximal  portion  of  the  dilatation  for  twenty- 


178  THU  BLOOD  VESSELS 

V 

four  hours  beginning  under  anesthesia  is  the  method  usually  fol- 
lowed. 

Surgical  treatment  should  be  considered.  In  selected  cases  the 
injured  artery  may  be  repaired  very  efficiently.  Each  patient 
requires  special  consideration  as  to  the  technique  to  be  employed. 

Prognosis.  Recovery  may  occur  in  the  smaller  arteries,  in  the 
dissecting  aneurysms,  and  sometimes  in  the  peripheral  sacular 
forms,  through  thrombosis  or  occlusion.  In  terminal  arteries,  the 
infarct  thus  formed  may  cause  serious  symptoms  or  death.  The 
danger  of  embolism  during  the  formation  and  organization  of  clot 
must  be  remembered;  this  danger  is  slightly  lessened  by  prevent- 
ing sudden  variations  in  the  blood  pressure  or  in  the  position  of 
the  body.  The  outlook  is  always  grave,  and  sudden  death  may 
occur  from  rupture,  embolism,  pressure  upon  vital  organs,  nerves, 
or  from  disease  in  distant  organs  resulting  from  the  circulatory 
disturbance. 

VARICOSE  VEINS  AND  HEMORRHOIDS 

(Phlebectasia;  varix;  varicosities) 

Veins  which  lose  their  elasticity  and  become  permanently 
dilated  from  the  pressure  of  the  blood  within  them  are  called 
varicose.  The  condition  is  characterized  clinically  chiefly  by  pres- 
sure symptoms.  When  the  venous  walls  break  down,  or  when  the 
nutrition  of  surrounding  tissues  become  lessened  by  the  disturbed 
circulation,  varicose  ulcers  are  apt  to  occur.  These  are  usually 
very  indolent,  obstinate  and  not  particularly  painful  unless  nerve 
trunks  are  involved. 

Etiology.  Phlebitis  and  phlebosclerosis  weaken  the  vessel 
walls,  and  thus  predispose  to  varicosities.  The  most  important 
factor  is  an  impediment  to  the  onward  flow  of  venous  blood.  Veins 
which  have  no  valves,  and  those  subjected  to  the  effects  of  gravity 
are  most  apt  to  be  affected ;  this  places  the  largest  number  of 
varicosities  in  the  legs  and  the  rectum.  Women  suffer  more  than 
men ;  probably  partly  on  account  of  dress ;  partly  the  puerperal 
state,  and  partly  lack  of  exercise.  Cardiac  and  hepatic  disease 
especially  delay  the  flow  of  blood  and  lead  to  hemorrhoids  as  well 
as  to  varicosities  of  the  legs. 

Bony  lesions  affecting  the  centers  controlling  the  vessels 
affected  must  be  considered  important  in  etiology.  This  is  espe- 
cially found  to  be  true  in  hemorrhoids. 

Hemorrhoids  are  dilated  hemorrhoidal  veins.  Especially  when 
the  portal  circulation  is  obstructed,  collateral  circulation  is  apt  to 
be  reestablished  partly  by  means  of  the  relations  of  the  hem- 
orrhoidal veins  with  the  vena  cava.  Thus  the  veins  are  sub- 
jected to  greatly  increased  pressure,  and  hemorrhoids  result. 


VARICOSB  ULCERS  179 

Internal  hemorrhoids — those  which  do  not  protrude  beyond 
the  external  sphincter — are  more  painful  and  more  urgent  causes 
of  the  neuroses  than  are  the  external — those  which  do  protrude 
beyond  the  sphincter. 

The  passage  of  feces  over  the  tumors  usually  erodes  the  mem- 
branes; these  areas  become  infected  with  tubercle  bacilli  or  other 
bacteria,  and  varying  degrees  of  fistulous  and  burrowing  abscesses 
result.  Very  obstinate  and  serious  tissue  destruction  may  thus 
be  initiated.  The  condition  is  much  worse  when  the  fecal  masses 
are  hard  and  dry  and  when  defecation  is  attended  with  straining. 
The  relation  of  constipation  (q.  v.)  to  hemorrhoids  is  evident. 

The  rupture  of  the  veins  into  the  surrounding  subcutaneous 
tissues  may  be  followed  by  the  coagulation  and  organization  of 
the  blood,  and  the  formation  of  nodular  masses  of  scar  tissue  which 
may  be  responsible  for  serious  nervous  disturbances.  Or  the 
hemorrhagic  blood  may  become  infected,  and  thus  abscesses  of 
varying  extent  may  result. 

The  treatment  of  dilated  veins  includes  the  correction  of  the 
causative  factors,  when  this  is  -  possible.  Hemorrhoids  require 
relief  of  the  constipation,  and  the  use  of  such  oil  or  water  enemas 
as  are  necessary  to  secure  very  soft  feces  and  easy  defecation.  The 
hepatic  and  cardiac  diseases  must  receive  suitable  treatment. 
Uterine  mal-positions,  neoplasms,  and  enlarged  prostates  must 
receive  suitable  care.     Rest  in  bed  is  most  helpful. 

Patients  must  not  sit  to  rest  when  the  recumbent  position  is 
possible;  they  must  not  stand  for  long  times  under  any  circum- 
stances. Correction  of  the  coccygeal,  sacral,  innominate  and  lum- 
bar lesions  is  very  important.  Unduly  contracted  sphincters  should 
be  treated  by  very  slow  and  easy  dilatation.  Pain  is  to  be  avoided 
as  much  as  possible  in  this  work. 


VARICOSE  ULCERS 

These  result  from  the  breaking  down  of  the  tissues  in  the 
neighborhood  of  a  varicose  vein — this  may  or  may  not  be  asso- 
ciated with  rupture  of  the  vein.  The  tissue  injury  is  marked,  and 
the  constant  pressure  exerted  by  the  varicosity  makes  such  ulcers 
chronic  and  resistant  to  the  usual  therapeutic  measures. 

Treatment-.  Correction  of  innominate  and  lumbar  lesions  is  of 
first  importance.  Leg  movements  which  facilitate  the  flow  of 
blood  upward  should  be  frequently  given,  even  if  no  apparent 
tension  exists  around  the  groin.  All  tissues  around  Poupart's  liga- 
ment and  the  sciatic  notch  must  be  watched  and  kept  relaxed.  The 
ulcer  itself  is  not  to  be  handled,"  though  very  careful  crowding  of 
the  surrounding  tissues  toward  the  ulcer,  thus  filling  it  with  fresh 
blood  and  lymph  which  is  immediately  drained  away  when  the 


180  THE  BLOOD  VESSELS 

pressure  is  again  relieved,  is  helpful.  The  patient  should  lie  down 
several  times  during  the  day,  even  if  he  can  only  rest  for  a  few 
minutes  this  relief  of  the  tension  is  useful.  The  use  of  the  elastic 
stocking  or  of  elastic  bandages  depends  upon  the  individual  con- 
ditions. If  the  patient  is  able  to  spend  considerable,  time  lying 
down,  or  to  remain  in  bed  most  of  the  day,  the  most  rapid  recovery 
occurs  with  no  pressure  upon  the  leg  at  all.  If  he  must  be  on  his 
feet  for  long  intervals,  some  support  is  usually  required. 

In  all  cases,  the  correction  of  whatever  structural  conditions 
may  be  found,  which  could  interfere  either  directly  or  indi- 
rectly with  the  circulation  or  with  the  nervous  control  of  the  legs, 
is  a  very  important  factor  in  the  treatment  of  the  varicose  veins  as 
well  as  of  the  varicose  ulcers. 


EPISTAXIS 
(Nose  bleed) 

Bleeding  at  the  nose  may  occur  as  the  only  symptom  in  any 
one  of  a  number  of  distinct  diseases.  Wounds  of  the  nasal  mucosa 
do  not  usually  present  any  difficulty  in  diagnosis.  Nasal  polyps, 
ulcers,  or  merely  hyperemia  of  the  mucous  membrane  may  be 
responsible  for  the  condition.  The  latter  factor  is  no  doubt  asso- 
ciated with  bony  lesions  in  the  upper  cervical  or  the  upper  thoracic 
region.  Fracture  of  the  base  of  the  skull  usually  produces  rather 
obstinate  nasal  hemorrhage.  Influenza,  syphilis  and  a  number  of 
other  infectious  diseases  may  so  act  upon  the  blood  as  to  prevent 
coagulation ;  for  this  reason  children  who  are  liable  to  attacks  of 
nose  bleed  upon  slight  provocation  should  be  very  carefully  pro- 
tected. Hemophilia,  pernicious  anemia  and  leukemia  may  show  as 
the  first  symptom  an  attack  of  nose  bleed.  Vicarious  menstrua- 
t^ion  should  be  mentioned.  Changes  in  atmospheric  pressure,  espe- 
cially rapid  ascent  of  a  mountain  or  other  rapid  elevation,  may 
cause  nose  bleed.  Nose  bleed  may  be  symptomatic  of  high  blood 
pressure. 

Treatment.  For  the  relief  of  the  attack  an  ice  bag  or  a  cloth 
wet  in  cold  water  may  be  placed  around  the  neck.  The  nose 
may  be  packed  in  obstinate  cases;  this  is  rather  to  be  avoided 
if  possible.  Steady  pressure  in  the  suboccipital  region  lowers 
the  general  blood  pressure;  steady  pressure  over  the  region  of 
the  eighth  to  the  tenth  transverse  processes  dilates  the  splanch- 
nic vessels,  and  mechanically  draws  the  blood  from  the  head 
region.  During  the  intervals,  in  habitual  cases,  the  cause  of  the 
weakness  should  be  found  and  removed,  if  possible.  The  prognosis 
depends  upon  the  cause  of  the  bleeding. 


PART  III 
DISEASES  OF  THE  RESPIRATORY  TRACT 


GENERAL  DISCUSSION 

Certain  structural  peculiarities  determine  the  character  of  the 
diseases  to  which  the  respiratory  tract  is  subject.  The  air  should, 
normally,  pass  into  the  lungs  by  way  of  the  nasal  passages.  These 
are  tortuous  and  are  lined  with  a  moist  ciliated  epithelium.  Thus 
the  air  is  cleaned,  warmed  and  moistened  before  reaching  the 
more  delicate  tissues  of  the  lungs. 

In  the  upper  respiratory  tract  the  mucous  membrane  is 
attached  rather  loosely  to  the  underlying  bones.  It  is  highly  vas- 
cular and  the  blood  vessels  are  controlled  from  the  vasomotor 
centers  in  the  upper  thoracic  spinal  column,  by  way  of  the  cervical 
and  cranial  sympathetics.  The  lymph-flow  depends  upon  the  cir- 
culation. The  nutrition  of  all  these  tissues  is  controlled  by  the 
same  nerve  mechanism. 

Bacteria  and  dust  are  usually  expelled  through  the  action  of 
the  cilia  and  of  the  secretions.  Infectious  agents  may,  however, 
gain  entrance  by  way  of  injuries,  or  as  the  result  of  impeded  cir- 
culatory conditions.  Bony  lesions  of  the  cervical  and  upper  dorsal 
region  are  important  factors  in  modifying  the  circulation  and  lower- 
ing the  resistance  to  infection. 

■'The  nerve  mechanisms  in  the  respiratory  field,  from  their  complexity 
and  comparatively  close  relations  to  grosser  structures,  are  more  susceptible  to 
lesion,  and  will  show  greater  pathological  effects  from  lesion  of  slight  degree, 
than  perhaps  any  other  part  of  the  body.  The  cranial  and  upper  spinal  nerves, 
cervical  and  dorsal,  are  affected  by  slight  derangement  of  vertebrae  or  ribs  or 
their  muscular  or  ligamentous  attachments.  The  sympathetic  chain  lies  in  close 
relation  to  the  anterior  aspect  of  the  lateral  spinous  processes,  and  the  heads 
of  the  ribs,  and  in  the  dorsal  region  is  bound  down  by  the  pleura  to  the 
spinous  processes  and  to  the  heads  of  the  ribs.  Nearly  all  these  nerves  contain 
fibers  of  vasomotor  function,  which  are  rather  widely'  distributed  in  a  sort  of 
'cross-reference'  manner.  ...  A  lesion  at  any  point  may  affect  any  one 
of  a  number  of  structures,  or  a  given  pathological  condition  may  be  due  to 
lesion  at  any  one  of  several  points." — C.  M.  T.  Hulett. 

"The  lungs  receive  vasomotor  impulses  by  way  of  the  following  structures : 
The  white  rami  communicantes  leaving  the  cord  with  the  second  to  the  fifth 
dorsal  nerves  (probably  chiefly  the  third  and  fourth),  then  through  the  lateral 
chain  of  sympathetics  to  the  cervical  ganglia,  in  one  of  which  a  relay  is  made; 
then  by  gray  fibers  to  the  vagus,  with  which  they  are  carried  to  the  pulmonary 
plexus.  Vaso-constrictor  impulses  may  be  increased  reflexly  by  the  stimula- 
tion of  sensory  nerves  ending  in  the  tissues  near  the  second  to  the  fifth  dorsal 
spines.  Vaso-constrictor  impulses  may  be  decreased  by  lessening  the  sensory 
impulses  by  steady  pressure  upon  the  same  tissues. 

181 


182  THE  RBSPIRATORY  TRACT 

"Osteopathic  inhibition  imitates  the  condition  produced  by  the  bony  lesion 
and  the  muscular  contraction;  hence  the  influence  of  these  in  producing  chronic 
pulmonary  congestion." — Pearl  A.  Bliss. 

The  nervous  control  of  the  circulation  through  the  upper  lobes 
of  the  lungs  is  from  the  second  to  the  fourth  spinal  segments  and 
for  the  lower  lobes,  from  the  third  to  the  fifth.  Diseases  aflfecting 
the  upper  lobes  of  the  lungs  give  reflex  muscular  contractions  of  the 
upper  thoracic  segments,  while  diseases  of  the  lower  lobes  give 
reflex  muscular  contractions  involving  the  fourth  to  the  seventh 
thoracic  segments.  A  certain  degree  of  localization  of  the  injured 
area  may  be  made  in  this  way. 

The  circulation  through  the  lungs  is  profoundly  modified  by 
variations  in  the  systemic  blood  pressure.  When  any  great  area 
of  the  systemic  arterial  system  is  dilated,  as  for  example,  the 
splanchnics,  the  lungs  are  left  comparatively  ischemic.  The  place 
of  abdominal  congestions  in  modifying  the  circulation  and  the 
nutrition  of  the  lungs  is  thus  evident. 

The  activities  of  the  respiratory  center  are  modified  by  varia- 
tions in  the  circulating  blood  and  by  emotional  states.  Both  these 
factors  may  be  important  etiological  factors  under  certain  condi- 
tions. The  turgidity  of  the  nasal  membranes  during  the  influence 
of  emotions  is  well  known,  and,  under  repeated  or  constant  emo- 
tional excitement,  may  become  effective  in  promoting  mouth- 
breathing,  with  resulting  irritation  of  the  lower  respiratory  tract 
and  various  disturbances  of  the  nasal  membranes.  Whenever  res- 
piratory variations  are  noticed,  an  investigation  of  the  habits  of 
the  patient,  especially  of  those  habits  usually  associated  with  emo- 
tional stress,  should  be  carefully  made,  and  treatment  of  such  cases 
should  include  the  correction  of  bad  habits  as  well  as  of  faulty 
bodily  structure. 


CHAPTER  XVIII 
DISEASES  OF  THE  NOSE 

ACUTE  RHINITIS 

(Acute  nasal  catarrh;  acute  coryza;  "cold  in  the  head") 

Acute  rhinitis  is  an  acute  catarrhal  inflammation  of  the  nasal 
mucous  membranes  characterized  by  headache,  slight  fever,  sneez- 
ing, and  dryness  of  nasal  membranes,  followed  by  abundant  secre- 
tion. 

Etiology.  The  most  common  etiological  factor  is  muscular  con- 
tractions along  the  spine.  These  may  be  caused  by  cold  draughfs 
on  the  back  of  the  neck,  gastro-intestinal  irritation,  etc.,  or  by  sub- 
luxations of  the  upper  cervical,  third  to  seventh  dorsal,  or  the 
lumbo-sacral  vertebrae.  Infection  by  the  micrococcus  catarrhalis 
is  responsible  for  epidemics.  Staphylococcus  or  streptococcus  or 
both,  may  be  present.  It  must  be  remembered  that  the  symp- 
toms of  acute  rhinitis  occur  in  the  initial  stages  of  certain  other' 
acute  infectious  diseases. 

Diagnosis.  The  condition  is  preceded  by  lassitude,  weariness, 
more  or  less  headache,  and  sneezing,  these  followed  by  chilliness, 
then  slight  fever,  100°  to  101°  F.,  and  dryness  of  the  nares.  This 
stage  is  followed  by  abundant  watery  saline  secretion  from  the 
nostrils  and  a  sense. of  fullness  in  the  nose,  which  may  be  momen- 
tarily relieved  by  blowing  the  nose. 

The  anterior  nares  are  red  and  the  eyes  are  suffused.  Later, 
the  discharge  becomes  purulent.  The  voice  is  peculiar,  nasal  and 
mufifled.  When  the  attack  is  nearing  recovery,  hard  crusts  form 
on  the  septum  and  turbinates  and  are  expelled  with  difficulty.  The 
complications  vary  in  intensity.  Labial,  more  rarely  nasal,  herpes 
may  occasion  considerable  discomfort.  Extension  of  the  inflam- 
.mation  to  the  accessory  sinuses  and  adjacent  tissues  is  frequent. 
If  to  the  frontal,  ethmoidal,  or  sphenoidal  sinuses,  there  is  severe 
headache ;  if  to  the  antrum  of  Highmore,  tenderness  over  the 
cheeks ;  if  to  the  Eustachian  tubes  and  middle  ear,  temporary 
deafness  results ;  if  to  the  pharynx  or  larynx,  cough  results.  Con- 
junctivitis is  less  frequent.  Chronic  rhinitis  is  apt  to  follow 
repeated  attacks. 

Treatment.  Correct  lesions  of  the  cervical  spinal  column  espe- 
cially ;  correct  mandibular  lesions.  Careful  work  over  the  superior 
cervical  glands  promotes  drainage.  Stimulating  treatment  over 
the  branches  of  the  fifth  nerve,  springing  the  mandible,  and  pres- 
sure over  the  upper  part  of  the  nose,  suddenly  relieved,  are  all 

183 


184  THE  NOSE 

useful  palliative  measures.     In  some  cases  of  streptococcus  infec- 
tion the  treatment  may  be  tedious. 

If  the  accessory  sinuses  become  infected  expert  consultation 
may  be  required,  though  many  cases  clear  up  by  careful  osteopathic 
treatment, 

"Secure  temporary  relief  from  the  general  contractions  in  the  spinal  muscu- 
lature. For  this,  the  familiar  'Dana  bend',  may  answer  or  any  forcible 
hyperflexion  of  the  spine  carefully  and  gradually  applied.  *  *  *  Relax 
general  spinal  contractions ;  treat  regional  contraction  apparently  involved ; 
relieve  the  head  congestion  by  securing  relaxation  of  the  supra-  and  infra- 
hyoid muscles ;  treat  upper  cervical  articulations ;  avoid  suddtn  force ;  leave 
no  contractions;  vary  the  order  of  procedure  if  any  one  contraction  group 
fails  to  relax.  If  a  muscle  is  hurt  or  an  important  irritable  lesion  is  over- 
looked,   failure   is  usual." — J.   A.    MacDonald. 

A  few  meals  omitted,  a  fruit  or  milk  or  very  restricted  diet, 
plenty  of  hot  drinks  to  promote  diaphoresis  and  cleansing  of  the 
bowels,  out-door  life,  moderate  exercise,  plenty  of  sunshine  pro- 
mote speedy  recovery  and  prevent  relapse. 

Prognosis.  If  taken  early,  one  treatment  often  suffices  to 
relieve  the  condition  and  complete  recovery  follows  within  a 
short  time.  In  very  young  infants,  loss  of  flesh  and  strength  may 
follow  from  inability  to  nurse. 

CHRONIC  RHINITIS 

(Chronic  coryza;  chronic  nasal  catarrh) 

Chronic  rhinitis  is  chronic  inflammation  of  the  nasal  mucosa 
producing  structural  changes  and  characterized  by  a  feeling  of 
fullness  in  the  nose,  "hawking,"  and  the  discharge  of  a  thick 
muco-purulent  secretion. 

Etiology.  Repeated  attacks  of  the  acute  form ;  continued  inha- 
lation of  irritating  vapors  or  dust;  chronic  subluxations  of  the 
cervical  and  upper  dorsal  vertebrae,  the  ribs,  and  the  mandible  are 
the  most  frequent  causes. 

Diagnosis.  Three  forms  are  recognized,  which  are  often  three 
stages  in  the  progress  of  the  disease  in  one  person. 

Simple  chronic  catarrh  is  an  early  stage  marked  by  liability  to 
"take  cold,"  when  the  mucous  membrane  speedily  becomes  con- 
gested and.  swollen.  Occasionally  stenosis  follows,  and  an  over- 
abundant thick  secretion.  If  it  persists,  it  develops  into  the 
second  stage,  hypertrophic  rhinitis.  In  this  form  the  lower  tur- 
binates are  swollen  and  enlarged,  there  is  a  constant  "hawking" 
to  remove  the  thick  secretion,  and  the  patient  becomes  more  or 
less  a  mouth-breather.  The  pharyngeal  and  adenoid  tissues  may 
become  coincidentally  affected  (naso-pharyngeal  catarrh).  The 
voice  becomes  nasal  and  varying  degrees  of  deafness  occur. 

Atrophic  rhinitis  may  follow  the  hypertrophic,  but  is  not  nec- 
essarily a  sequence.     The  mucosa  is  shrunken  and  atrophic  pro- 


CHRONIC  RHINITIS  185 

ducing  an  abnormal  roominess  in  the  nasal  cavity.  Crusts  of 
disgusting  odor  (ozena)  are  frequently  present.  In  any  of  these 
forms,  sudden  change  in  the  weather  is  liable  to  cause  an  acute 
exacerbation.  Rhinoscopic  examination  show's  the  characteristic 
structure  of  the  membranes. 

Treatment.  "There  are  two  principles  of  treatment  in  catarrhal 
conditions :  First,  removal  of  the  cause  of  overgrowth  of  tissue 
and  overstimulation  of  function.  Second,  the  institution  of  meas- 
ures to  absorb  some  part,  if  possible,  of  the  excessive  connective 
tissue  already  formed,  and  to  restore  normal  function  to  such 
cells  of  higher  type  as  have  not  suffered  irreparable  injury.  The 
hygiene  of  the  individual  demands  careful  attention.  This  includes 
the  closest  investigation  of  the  habits  of  relaxation,  bathing,  sleep- 
ing and  dress.  Sexual  perversions  are  to  be  considered,  bearing 
in  mind  the  reflexes  from  an  adherent  clitoris  or  prepuce.  Elim- 
ination must  be  carefully  watched  and  the  kidneys,  liver,  pancreas, 
and  intestines  may  have  much  to  tell. 

"The  first  hint  of  diabetes  or  Bright's  disease  may  be  given  by 
the  dry,  scratchy  feel  of  the  mucous  membrane  of  the  throat.  *  *  * 
Relaxation  can  be  maintained  by  aid  of  either  hot  or  cold  com- 
presses or  warm  bottles,  while  wet  packs  of  various  temperatures 
and  full  baths  are  often  useful  to  promote  elimination.  Local 
douches  of  normal  salines  are  indicated  at  times,  especially  in 
ozenic  and  atrophic  conditions  with  crust  formations.  Their  use 
is  rarely  justified  in  acute,  non-purulent  discharges.  *  *  *  Copious 
drinks  of  water,  either  hot  or  cold,  sometimes  distilled  and  often 
acidulated,  are  indicated  for  eliminative  reasons.  Fruit  juices  are 
also  helpful. 

"To  control  the  negative  pressure  conditions,  conservative  sur- 
gery must  be  employed  when  indicated. 

"After  the  correction  of  all  abnormal  physical  relations  and  the 
application  of  such  remedial  measures  as  are  indicated  in  each 
case,  the  next  step  is  the  education  of  the  patient  in  correct  habits 
of  sitting,  standing,  walking,  and  breathing,  with  prescription  of 
special  exercises  for  the  correction  of  weak  structural  conditions." 
— Mary  S.  Croswell. 

Prognosis.  Recovery  is  to  be  expected  in  the  simple  catarrhal 
form.  Symptomatic  recovery  may  occur  in  the  hypertrophic  and 
atrophic  forms,  though  very  often  the  pathological  tissues  remain 
a  source  of  irritation  through  life.  The  disease  does  not  seem  to 
shorten  life,  but  it  very  materially  lessens  the  comfort  and  effi- 
ciency of  the  patient,  and  it  is  an  important  cause  of  deafnes^. 

NASAL  POLYPS.  These  are  pedunculated  tumors  which  grow  from  the 
nasal  membranes,  and  restrict  the  air  passages.  They  are  called  fibrous,  mucous 
or  serous,  according  to  the  preponderance  of  connective  tissue,  serum,  or 
mucous  secretion  within  their  sacs. 


186  THE  NOSE 

The  membranes  of  the  nasal  passage  are  rather  loosely  bound  to  the  under- 
lying bones,  are  highly  vascular,  and  both  the  membranes  and  the  vessels  are 
freely  supplied  with  sensory  and  sympathetic  nerves.  Disturbed  innervation 
or  nutrition  of  the  membranes  or  vessel  walls  permits  an  overfilling  of  the 
lyinph  spaces  and  the  blood  vessels ;  these  factors  are  due  to  repeated  attacks 
of  rhinitis;  the  inhalation  of  irritating  gases  or  dust;  and  especially  to  bony 
or  other  lesions  of  the  mandibular,  hyoid  or  cervical  areas.  When  there  is  a 
loss  of  tone  of  either  vessels  or  membrane,  the  weight  and  the  negative  pres- 
sure thus  established  permit  further  dropping,  the  loosened  membrane  fills 
ccnstantly,  and  this  weight  acts  as  further  irritant.  Whether  the  tumor  merely 
fills  with  lymph  and  blood  serum,  or  whether  mucous  cells  are  plentifully 
included  in  the  affected  tissue,  or  whether  the  connective  tissue  cells,  having 
excellent  opportunity,  unduly  multiply,  is  due  to  structural  relations  of  the 
particular  areas  affected. 

When  the  polyp  has  become  recognizable,  its  surgical  removal  is  indicated. 
If  this  is  all  that  is  done,  later  growths  are  very  apt  to  appear.  But  if  the 
factors  responsible  for  the  growth  are  removed — bony  lesions,  especially — the 
growth  of  successive  crops  of  polyps  should  be  prevented.  After  any  polyp 
has  been  removed,  osteopathic  treatment  for  the  rem.oval  of  lesions  as  found 
should  follow  immediately,  and  the  patient  should  be  examined  at  intervals  for 
a  year  or  more,  in  order  that  further  injury  to  the  membrane  may  be  avoided. 

RED  NOSE.  The  nose  is  subject  to  considerable  variation  in  circulation. 
Sometimes  the  dilatation  of  the  blood  vessels,  especially  near  the  end  of  the 
nose,  causes  great  annoyance  to  the  patient.  Normally,  the  nose  is  rather  paler 
than  the  rest  of  the  face,  even  during  blushing.  The  most  common  cause  of 
red  nose  is  the  use  of  alcohol;  and  this  fact,  which  is  generally  recognized,  is 
responsible  for  much  of  the  discomfort  that  attends  the  presence  of  red  nose 
iuNtemperate  individuals. 

Other  common  causes  of  red  nose  include :  gout ;  nephritis ;  sexual  disturb- 
ances; over  eating  of  any  one  article  of  diet,  as  sweets,  starches,  meats,  pastries; 
the  use  of  excessive  amounts  of  spices,  tea,  coffee,  tobacco,  and  "soft  drinks," 
especially  of  the  sweet  varieties;  chronic  rhinitis,  and  certain  local  affections, 
as  eczema,  etc.  Occasionally  no  cause  can  be  found,  though  the  nose  is  as  red 
and  rough  as  in  habitual  alcoholics. 

The  place  of  the  bony  lesion  in  these  cases  has  been  found  important  in  a 
few  cases.  The  structural  changes  associated  with  red  nose  are  so  profound, 
however,  that  the  correction  of  the  lesions  is  effectual  in  leading  to  relief  of 
the  condition  only  in  mild  cases. 

The  treatment  consists  in  the  removal  of  the  causative  factors,  for  the 
most  part.  Local  applications  of  soothing  ointment  and  very  mild  astringents 
may  give  some  relief.  It  is  necessary  to  avoid  anything  irritative,  lest  the 
later  condition  be  worse  than  the  first. 

HAY  FEVER 

(Rose  or  June  cold;  autumnal  catarrh) 

Hay  fever  is  an  affection  of  the  upper  air  passages  due  to  the 
effects,  probably  toxic  or  anaphylactic,  of  certain  pollens  acting 
upon  a  hypersensitive  mucous  membrane,  characterized  by  sneez- 
ing, increased  lachrymation,  headache,  and  a  watery  nasal  dis- 
charge. 

Etiology.  It  seems  to  be  a  neurotic  idiosyncrasy  manifested 
as  a  morbid  sensitiveness  of  the  nasal  mucosa  to  the  action  of  the 
pollen  of  grasses  and  of  certain  plants,  sometimes  of  dust.  Sub- 
luxations and  contractions  are  found  from  the-  atlas  to  the  fifth 


HAY  FEVER  187 

dorsal  vertebrae  and  the  upper  three  ribs,   and   clavicle.     Local 
disease  of  the  nasal  membrane  may  be  responsible. 

Diagnosis.  The  condition  begins  as  an  ordinary  oold ;  sneezing 
is  very  frequent;  there  is  more  or  less  headache  and  distress;  the 
patient  becomes  low-spirrted ;  cough  is  common;  the  eyes  are 
watery,  with  itching  and  smarting  especially  at  the  inner  canthus ; 
asthmatic  attacks  are  common  and  may  alternate  with  the  hay 
fever.  Taste,  smell,  and  hearing  are  impaired.  An  attack  usually 
lasts  four  to  six  weeks. 

Treatment.  The  care  of  each  individual  must  be  based  upon 
the  results  of  personal  study.  Probably  no  two  people  are  affected 
in  exactly  the  same  way,  nor  is  the  etiology  the  same  in  any 
great  number  of  cases.  The  etiological  factors  must  be  removed 
as  found,  if  recovery  is  to  be  permanent.  Correction  of  the  cervical 
and  upper  thoracic  bony  lesions  results  in  recovery  in  certain  indi- 
viduals ;  removal  of  nasal  deformities  is  necessary  when  these 
exist ;  some  cases  are  essentially  neurotic,  and  the  treatment  must 
be  dependent  upon  the  constitutional  findings ;  in  every  case  it  is 
necessary  to  find  the  essential  cause  of  the  neurosis,  if  possible. 
There  are  many  people  who  can  only  be  sent  to  a  pollen-free 
locality  every  year.  Relief  of  the  attack  may  be  secured  very 
often,  by  special  manipulations. 

"Treatment  consisted  in  traction  to  left  for  freeing  right  nasal  artery  and 
traction  to  right  to  free  left  artery.  This  gave  local  relief,  though  I  have  re- 
garded freeing  tension  around  axis  and  atlas  as  the  curative  treatment." — 
Ella  R.  Gilmour. 

"I  firmly  believe  the  typical  case  will  never  fail  in  responding  to  the  vaso- 
motor ceflex  existing  between  the  tenth  dorsal  and  the  Schneiderian  mem- 
brane. This  reflex  I  excite  by  having  the  patient  lie  on  stomach  on  table,  and 
exerting  deep  steady  pressure  over  tenth  dorsal  spinous  process  (straddling 
process  with  end  of  thumb,  and  first  finger  flexed  at  first  distal  joint)." — A.  M.^ 
Smith. 

"While  treating  hay  fever  this  season,  I  found  that  fifty  per  cent  of  the 
attacks  could  be  arrested  by  soft  palate  manipulation  alone;  and  in  those  cases 
which  did  not  respond,  the  condition  was  immediately  relieved  by  a  dilatation 
of  the  epi-naris,  with  the  intra-nasal  technique.  .  .  .  However,  both  of  the 
local  treatments  were  supported  by  a  daily  normal  saline  irrigation  of  the  naso- 
pharynx, and  the  adjustment  of  the  osteopathic  lesions." — J.  D.  Edwards. 

J.  Deason  reports  excellent  results  from  nasal  irrigation  with  hot  1% 
solution  of  salt,  borax  and  soda,  3-2-1,  beginning  at  108°  F.  and  raising  to  117° 
or  even  higher.  One  to  five  quarts  of  water  should  be  used  at  each  irrigation, 
and    a   non-irritant   lubricant,   as   chondrus   jelly,    applied    after    the   irrigation. 

"Digital  treatment  of  post-nasal  region  through  pharynx  is  good.  Pressure 
over  terminals  of  fifth  and  other  sensory  nerves — one  finger  in  nares,  thumb  on 
outside — controls   attacks." — J.   Deason. 

Prognosis.  When  the  treatment  can  be  begun  before  the 
symptoms  have  appeared,  the  prognosis  is  good  for  prevention. 
After  the  characteristic  symptoms  have  appeared,  relief  may  be 
secured.  In  very  obstinate  cases,  change  of  climate  for  one  or  two 
summers  may  be  necessary.  Persistent  treatment  in  the  interven- 
ing months  should  result  in  obviating  this  need. 


CHAPTER  XIX 
ADENOIDS  AND  TONSILS 

ACUTE  TONSILLITIS 

(Acute  amygdalitis ;   follicular  tonsillitis ;  parenchymatous  tonsillitis ;  herpetic 

tonsiUitis) 

This  is  an  acute  inflammation  of  one  or  both  tonsils,  affecting 
variously  the  tonsillar  layers,  and  resulting  in  more  or  less  per- 
manent injury  to  the  tonsil  affected.  The  inflammation  is  of  a 
simple  parenchymatous  type  with  marked  congestion  of  the 
glands,  hyperplasia  of  the  lymphoid  elements,  exudation  and  des- 
quamation of  the  epithelium. 

Etiology.  Predisposing  causes  are  lesions  of  the  cervical  ver- 
tebrae, either  as  a  constant  condition  or  the  result  of  trauma. 
Mouth  breathing  and  malnutrition  of  any  kind  lower  resistance 
to  infection.  Exciting  factors  are  pyogenic  bacteria,  exposure  to 
cold,  and  trauma. 

Diagnosis.  The  onset  is  usually  sudden,  with  chilliness  or 
chill,  fever  (102°  to  103°  F.),  full  frequent  pulse,  headache,  often 
frontal,  tongue  coated,  breath  fetid ;  throat,  hot  and  dry.  The 
glands  at  the  angle  of  the  jaw  are  enlarged  and  there  is  pain  on 
moving  the  jaw  or  swallowing.  Reflex  contractions  affect  espe- 
cially the  hyoid  group  of  muscles,  the  anterior  cervical  group,  and 
the  upper  thoracic  spinal  muscles.  The  skin  of  the  neck  and  over 
the  angles  of  the  jaw,  as  well  as  the  tissues  associated  with  the 
muscles  named,  are  hypersensitive  to  pressure  and  to  cold. 

Inspection  reveals  the  tonsils  greatly  swollen  and  red,  covered 
with  a  creamy  mucopus,  or,  in  the  follicular  form,  the  surface  is 
covered  with  yellowish  rounded  masses  of  secretion  protruding 
from  the  mouths  of  the  follicles. 

In  some  cases  the  tonsil  may  be  covered  with  a  dirty-yellow 
membrane  which  strips  off  readily.  The  fever  usually  subsides  by 
crisis  on  the  third  or  fourth  day  and  resolution  takes  place.  Occa- 
sionally sequelae  follow  as  pneumonic  or  rheumatic  fever,  acute 
nephritis,  endocarditis,  pericarditis,  and  otitis  media. 

Cultures  should  be  made  to  distinguish  this  disease  from  diph- 
theria. In  herpetic  tonsillitis,  vesicles  appear  on  the  surface  of  the 
tonsil.  The  pain  is  very  severe,  and  the  constitutional  symptoms 
are  intense,  apparently  out  of  proportion  to  the  local  lesions. 

Leucocytosis  is  usually  present  in  all  forms  of  tonsillitis. 

Treatment.  "Adjust  the  inferior  maxillary  bone.  See  that 
the   structures  between   it   and   the   upper  cervical  vertebrae  are 

188 


ACUTE  TONSILLITIS  189 

set  free  on  both  sides  of  the  neck.  *  *  *  Adjust  whatever  slight 
irregularities  you  find  in  the  cervical  and  upper  dorsal  regions. 
Bring  your  clavicles  well  up  and  forward.  Look  carefully  to  your 
upper  four  ribs,  and  see  that  they  are  perfectly  adjusted  to  your 
sternum  and  spine.  Free  the  hyoid  bone  from  any  contracted 
muscles  which  could  bind  it.  *  *  *  Then  go  to  the  lumbar  re- 
gion and  treat  there  to  open  up  the  excretories.  See  that  the  lum- 
bar vertebrae  are  in  line,  and  that  the  floating  ribs  are  well  up 
and  in  their  proper  place.  Do  all  your  work  in  the  neck  region 
from  the  outside."— A.  T.  Still.. 

"The  first  effort  at  treatment  was  directed  to  the  relaxation  of  cervical 
and  dorsal  musculature;  then  gentle,  careful  effort  was  made  to  secure  move- 
ment at  fifth  cervical. 

"Next,  light  local  treatment  was  given  to  each  tonsil.  Besides  removing 
obstruction  to  the  lymphatics  and  other  vessels,  the  local  treatment  forced  from 
the  crypts  considerable  of  the  muco-purulent  material,  patient  clearing  throat 
after  each  attempt.  Each  tonsil  was  treated  in  this  way  three  times.  A  cold 
compress  was  placed  around  the  throat  and  patient  was  advised  to  gargle  with 
hot  normal  salt  solution  several  times  during  the  night,  if  awake;  he  was 
directed  to  take  all  the  water  he  wanted,  but  no  food.  .  .  .  Instructions 
were  given  for  colon  irrigation,  patient  afterward  saying  that  considerable  black, 
offensive  smelling  feces  was  passed.  Urine  was  normal.  .  .  .  Later,  more 
normal  motion  was  secured  at  points  of  bony  lesions;  patient  felt  very  well. 
.  The  local  treatment  to  the  tonsils  with  the  removal  of  infectious  mate- 
rial lodged  in  the  crypts,  is  important.  Treatment  to  the  lesions  present  was 
very  light  and  non-irritating." 

"In  all  acute  infections  such  as  tonsillitis,  I  pay  very  close  attention  to  the 
lower  dorsal  region,  with  a  view  to  normalizing  the  vaso-motor  control  to  the 
adrenal  bodies,  believing  as  I  do  that  the  liberation  of  their  secretion  greatly 
augments  the  auto-protective  forces  of  the  body.  I  am  thoroughly  convinced 
that  tonsillitis  both  acute  and  chronic  is  often  secondary  to  diseased  teeth  and 
gums.  The  lymphatics  from  the  teeth  and  peri-dental  structures  drain  by  way 
of  the  tonsils."— E.  C.  Bond. 

"It  is  a  mistake  to  think  that  strenuous  manipulative  measures  are  neces- 
sary in  relieving  tonsillary  conditions.  We  have  to  do  with  a  tissue  condition 
sensitive  and  inflamed,  contra-indicating  rough  manipulative  measures,  and  it 
is  remarkable  how  nicely  the  soft  cervical  tissues  can  be  handled  if  no  strong 
irritation  is  produced  while  treating.  It  is  not  uncommon  to  reduce  the  con- 
gestion within  a  few  moments'  time  sufficiently  for  the  patient  to  be  able  to 
swallow  with  some  degree  of  comfort. 

"It  is  well  to  remember  that  the  tonsil  is  a  lymphatic  structure  and  should 
not  be  directly  treated  as  a  rule.  If  so,  with  the  greatest  care.  It  is  not  always 
the  tonsil  that  we  feel  on  palpation,  but  the  Ij'mphatic  glands  and  tissues  over 
the  tonsil.  A  careful  correction  of  maxillary,  cervical  and  dorsal  lesions  is 
sufficient,  as  a  rule,  to  reduce  the  congestion,  although  gentle  treatment  is  some- 
times beneficial  over  the  tonsil." — F.  P.  Millard. 

Prognosis.  Recovery  is  the  rule,  unless  complications  arise. 
To  prevent  recurrence,  the  patient  must  be  instructed  in  general 
hygiene,  and  if  he  feels  the  slightest  indication  of  trouble  to  imme- 
diately see  his  osteopathic  physician.  Each  attack  increases  the 
danger  of  permanent  injury  to  the  tonsil. 


190  ADENOIDS  AND  TONSILS 

PERITONSILLAR  ABSCESS 

(Quinsy) 

Sometimes  an  attack  beginning  as  acute  tonsillitis  takes  a 
severer  form.  The  uvula,  soft  palate,  and  parts  around  the  tonsil 
appear  edematous,  swallowing  is  excessively  painful,  articulation 
is  difficult,  and  the  voice  is  nasal.  The  constitutional  symptoms 
are  more  severe  than  in  the  simple  form.  In  from  two  to  six  days; 
fluctuation  can  be  felt,  usually  in  the  soft  palate.  Quinsy  is  prob- 
ably due  to  the  presence  of  a  more  malignant  infectious  agent  than 
simple  tonsillitis. 

Treatment.  In  addition  to  the  treatment  given  under  acute 
tonsillitis,  incision  may  be  made  with  a  curved  bistoury  guarded 
nearly  to  the  point,  making  the  incision  from  above  downward 
parallel  with  the  anterior  pillar.  If  this  is  not  done  the  patient 
suffers  longer  and  the  abscess  ruptures  anteriorly  or  toward  the 
tonsil,  with  immediate  relief  of  the  symptoms  and  gradual  re- 
covery. 

In  rare  cases,  if  the  swelling  produces  symptoms  of  suffoca- 
tion, excision  or  tracheotomy  may  have  to  be  done. 


CHRONIC  TONSILLITIS  AND  ADENOIDS 

(Hypertrophy  of  the  tonsils;  aprosexia;  naso-pharyngeal  obstruction;  mouth- 
breathing) 

This  is  a  chronic  inflammation  of  the  tonsils  and  related  lymph- 
oid tissues,  characterized  by  hypertrophy  of  the  tissues  affected, 
and  symptoms  referable  both  to  mechanical  obstruction  of  the 
respiratory  passages  and  to  the  toxic  effects  of  infection. 

Etiology.  The  condition  is  most  frequent  before  and  during 
puberty ;  in  boys  more  often  than  in  girls ;  in  children  with  tuber- 
cular or  syphilitic  ancestry ;  in  those  who  live  under  insanitary 
conditions,  especially  those  kept  within  doors;  and  in  those  sub- 
ject to  recurrent  acute  tonsillitis.  Upper  thoracic  lesions  are  prac- 
tically invariably  present ;  lesions  of  atlas  and  axis  are  usually 
present.  Other  lesions  often  found  include  the  first  and  second 
ribs,  the  clavicle,  the  hyoid  and  mandible,  and  vertebrae  from 
occiput  to  mid-thoracic.  This  widespread  area  of  probable  etiolog- 
ical relationships  is  due  to  the  peculiar  vasomotor  innervation  of 
the  tonsils. 

Pathology.  Both  tonsils  are  usually  involved.  There  may  be  Increase 
in  the  lymphoid  elements  with  or  without  increase  in  the  stroma;  distension 
of  the  crypts  with  plugs  of  cheesy  yellowish  material  of  peculiar  offensive  odor 
— Dittrich's  plugs.  The  latter  may  become  infiltrated  with  lime  salts,  thus 
forming  concretions. 

Associated  with  hypertrophied  tonsils  is  usually  an  overgrowth  of  the 
pharyngeal    lymphoid   tissue.     This    may   be   papillomatous    with    a   lymphoid 


CHRONIC  TONSILLITIS  191 

parenchyma,  may  appear  as  masses  from  a  small  pea  to  an  almond  in  size,  or 
may  be  sessile  or  pedunculated.  The  tissue  is  reddish  in  color,  of  moderate 
firmness,  contains  numerous  blood  vessels,  and  is  most  abundant  over  the  vault 
of  the  pharynx  in  line  with  the  fossa  of  the  Eustachian  tube,  or  the  masses 
may  lie  posteriorly  in  the  fossa  of  Rosenmiiller,  or  upon  parts  parallel  to  the 
posterior  wall  of  the  pharynx. 

Diagnosis.  Chronic  tonsillitis  with  adenoids  is  responsible  for 
"mouth-breathing."  This  appears  at  first  at  night;  the  child  is 
restless,  awakes  with  ''night  terrors,"  and  snores  often.  A  short 
dry  cough  may  be  present,  due  partly  to  the  nervous  irritation  and 
partly  to  the  effects  of  the  mouth-breathed  air  upon  the  respiratory 
passages.  Recurrent  bronchitis,  pharyngitis,  laryngitis,  stuttering, 
asthma,  digestive  difficulties  and  various  functional  nervous  dis- 
turbances may  be  the  more  or  less  direct  results  of  chronic  ton- 
sillitis and  adenoid  growths.  Such  children  have  lowered  resist- 
ance to  infectious  diseases. 

The  face  of  the  mouth  breather  is  characteristic.  The  open 
mouth  and  the  loose  hanging  jaw  give  an  expression  of  stupidity 
which  may  or  may  not  be  deserved.  The  lips  are  usually  thick 
and  dry;  the  nose  is  broad,  the  nostrils  have  diminished  opening, 
and  the  edges  look  paler  and  somewhat  waxy.  The  "pigeon- 
breast"  or  "chicken-breast"  may  be  present.  A  thick  voice,  often 
hoarse,  slight  constant  headache,  slight  or  pronounced  deafness, 
and  some  mental  torpor  are  constant  in  those  who  have  been 
mouth-breathers  for  any  length  of  time. 

These  symptoms  should  lead  to  an  examination  of  the  patient. 
The  diagnosis  is  made  upon  palpation  and  inspection,  by  means 
of  which  the  enlarged  tonsils  and  the  adenoid  masses  in  the  naso- 
pharynx are  evident. 

Treatment.  Adenoids  are  abnormal,  and  should  be  removed 
whenever  they  are  large  enough  to  interfere  with  respiration.  Ton- 
sils are  useful  organs,  and  should  be  saved  if  possible.  Often  badly 
hypertrophied  tonsils  return  to  practically  normal  size  after  the 
removal  of  adenoids,  and  other  indicated  treatment  given.  When 
the  tonsils  are  filled  with  pus,  being  practically  destroyed  already, 
or  when  they  do  not  yield  to  careful  treatment,  interfering  with 
respiration  and  being  the  seat  of  constant  infectious  processes, 
they  should  be  removed  by  clean  and  complete  surgery. 

"The  restoration  of  the  normal  blood  supply  and  perfect  drainage  to  and 
from  the  organs  lessens  the  liability  to  contract  colds  or  to  the  recurrence  of 
the  acute  form  of  disease  known  as  tonsillitis." — A.  T.  Still. 

To  secure  this  end,  the  neck  and  upper  thoracic  areas  must  be 
kept  perfectly  adjusted,  the  ribs  normal  in  articulation  at  both  ends 
and  kept  raised  as  much  as  can  be  secured.  Every  effort  must  be 
made  to  secure  the  cooperation  of  the  child  in  taking  prescribed 
exercises.  Lifting  the  large  tonsils  and  giving  a  very  gentle  cir- 
cular motion  at  the  same  time  assists  in  draining  them.    Care  must 


192  ADENOIDS  AND  TONSILS 

be  taken  not  to  touch  the  pharynx,  as  gagging  will  result.  The 
hand  and  fingers  are  to  be  surgically  clean;  a  finger  cot  is  most 
easily  sterilized,  but  it  lessens  touch  sense. 

After  the  adenoids  have  been  removed,  and  after  respiratory 
interferences  due  to  enlarged  tonsils  have  disappeared,  there  may 
still  be  difficulty  in  overcoming  the  mouth-breathing  habit.  Sys- 
tematic breathing  exercises  are  good  to  facilitate  the  return  to 
the  normal  nose  breathing.  Exercises  that  retract  and  elevate  the 
soft  palate  are  beneficial;  also  forced  expiratory  exercises  that 
affect  the  entire  respiratory  tract.  Various  mechanical,  appliances 
are  now  on  the  market  for  holding  the  m.outh  closed  at  night. 
These  are  annoying  and  should  be  used  only  as  a  last  resort.  Much 
living  in  the  open,  both  during  day  and  night,  is  of  great  value  in 
securing  the  normal  respiratory  habits.  It  should  be  remembered 
that  diseased  tonsils  are  probably  a  frequent  source  of  infections 
elsewhere  in  the  body. 

"The  conclusions  were  that  the  adenoids  present  in  the  epipharynx  of  the 
child  was  the  prime  factor  in  the  production  of  deviated  septa,  hypertrophied 
and  other  ways  diseased  turbinates  and  all  forms  of  nasal  blocking,  also  for 
acute  and  chronic  catarrhal  changes  in  the  ear  with  all  their  sequelae,  for 
enlarged  tonsils  and  cervical  glands ;  and,  secondarily,  by  reason  of  the  chronic 
inflammation  induced  throughout  the  entire  area  of  mucous  membranes  of  the 
head  and  throat,  with  the  resultant  lowered  tissue  resistance  that  the  adenoid 
was  responsible  for  the  greater  proportion  of  the  exanthemata  of  childhood. 

"Secondly,  that  the  adenoid,  in  many,  if  not  all  instances,  was  the  resuft 
of  vasomotor  perversion  due  to  osteopathic  lesions  in  upper  dorsal  and  cervical 
regions  occurring  either  in  utero  or  during  the  first  few  years  of  life,  and  not 
due,  as  generally  stated,  to  syphilis  or  lymphoid  overgrowth  following  toxemia 
of  various  infectious  diseases." — Mary  S.  Croswell. 

"Briefly,  enlarged  tonsils  are  operative  when  they  really  contain  an  abscess, 
the  operation  simply  consisting  in  lancing.  They  are  also  operative  if  chron- 
ically or  at  frequent  intervals  enlarged,  and  when  osteopathic  treatment  has 
failed  to  reduce  them.  In  this  case  clipping  or  guillotining  is  usually  suffi- 
cient. 

"In  the  very  worst  cases  I  enucleate,  but  in  most  cases  I  am  perfectly 
satisfied  with  the  lesser  operation  as  it  usually  leaves  them  two  good  tonsils 
that  cto  get  smaller  and  still  have  good  functions,  while  the  dissection  operation 
robs  them  entirely  of  the  tonsils.  The  tonsil  is  a  normal  organ  while  adenoids, 
which  I  remove  entirely,  are  abnormal. 

"In  those  few  cases  where  cutting  off  the  top  is  a  failure,  they  can  still  be 
dissected  out  and  there  has  been  no  damage  done  and  rtothing  lost." — Geo. 
StUl. 

"Undoubtedly  surgery  must  be  resorted  to  in  specific  cases.  Repeated 
infection  serves  to  transform  the  lymphatic  tissue  to  a  mere  fibrous  shell  elimi- 
nating those  factors  essential  to  active  phagocytic  and  anti-toxic  power.  Gaping 
remnants  of  follicles  welcome  invading  bacteria  that  must  penetrate  to  the 
cervical  nodes  before  meeting  resistance.  Surgery  is  our  one  remedy,  tempered 
with  conservatism  and  judgment." — F.  C.  Farmer. 

"Irregularities  in  the  position  of  the  cervical  and  upper  thoracic  vertebrae, 
the  mandible,  the  hyoid,  or  the  upper  ribs,  are  probably  efficient  factors  in  the 
disturbed  circulation  and  thus  the  increased  tendency  to  abnormal  tonsillar  con- 
ditions and  the  growth  of  adenoids. 


ADENOIDS  193 

"The  correction  of  these  structural  abnormalities  is  a  necessary  part  of  the 
treatment  of  the  conditions,  whether  surgical  interference  is  indicated  or  not. 

"Every  effort  should  be  made  to  save  normal  tonsillar  tissue.  There  is  no 
reason  for  saving  masses  of  diseased  tissue  which  may  have  replaced  the 
tonsils. 

"Adenoids  large  enough  to  compel  mouth-breathing  should  be  removed. 
The  growths  are  not  apt  to  recur  if  the  spinal  conditions  and  the  hygienic  con- 
ditions are  corrected." — P.  C.  O.  Clinic  Report. 

"Adenoids  and  other  abnormal  nasal  conditions  are  important  causes  of 
mental  deficiency.  An  important  drainage-way  for  the  lymph  from  the  anterior 
fossa  of  the  skull,  and  thus  from  the  frontal  lobes  of  the  brain,  is  by  the 
perivascular  and  perineural  lymph  spaces  of  the  cribriform  plate.  Any  dis- 
ease which  interferes  with  this  drainage-way  must  exert  a  malevolent  influence 
upon  the  development  of  the  frontal  lobes  of  the  brain ;  in  the  case  of  adenoids, 
this  evil  influence  is  most  effective  at  the  time  of  life  when  the  frontal  lobes  are 
beginning  their  most  rapid  development. 

"Mouth-breathing  is  another  factor  in  promoting  inefficiency.  Not  only 
does  mouth-breathing  cause  mal-nutrition  of  the  brain,  as  of  the  rest  of  the 
body,  but  the  lax  state  of  the  jaw  muscles  seems  to  be  associated  with  faulty 
development  of  the  corresponding  nerve  cells  in  the  cortex.  The  entire  cerebral 
and  somatic  mechanism  concerned  in  what  is  usually  called  "strong-willed  per- 
sonality" is  weakened  by  the  open  mouth  and  the  drooping  mandible  of  the 
mouth-breather.  For  this  reason  surgical  interference  ought  not  to  be  too  long 
delayed," — L.  Burns. 


CHAPTER  XX 
^       DISEASES  OF  THE  PHARYNX  AND  LARYNX 

GENERAL  DISCUSSION 

The  pharynx  includes  several  varying  structures,  which  are 
variously  subject  to  disease,  but  which  are  anatomically  and 
physiologically  related.  The  tonsils  lie  between  the  pharyngeal 
pillars ;  the  respiratory  path  as  well  as  the  digestive  path  traverses 
the  cavity  of  the  pharynx.  The  membrane  lining  the  pharynx, 
larynx,  and  the  lower  digestive  and  respiratory  tracts  is  contin- 
uous, through  this  common  cavity,  with  the  membrane  of  the 
buccal  and  the  nasal  passages.  This  membrane  is  well  supplied 
with  blood  vessels,  lymphatic  paths,  lymph  nodes,  mucous  and 
serous  glands,  and  the  sensory  nerves  which  are  concerned  in  sev- 
eral varieties  of  sensations,  as  well  as  the  efferent  nerves  which 
govern  the  secretion  of  the  glands,  the  caliber  of  the  blood  vessels, 
and  the  tension  of  the  muscle  fibers  which  lie  beneath  the  mem- 
brane through  a  varying  extent  of  its  area. 

The  vasomotor  nerves  are  derived,  for  the  most  part,  from 
the  superior  cervical  ganglion,  and  also  from  others  of  the  sympa- 
thetic ganglia  of  the  cranial  and  cervical  region.  These,  in  turn, 
derive  stimulation  from  the  spinal  segments  of  the  upper  thoracic 
cord,  and  from  certain  visceral  centers  of  the  medulla,  pons  and 
mid-brain.  All  of  these  centers  are  active  according  to  the  im- 
pulses reaching  them,  which  are  ultimately  sensory  in  origin.  Ver- 
tebrae of  the  upper  thoracic  and  the  cervical  segments,  upper  ribs 
and  clavicles,  the  hyoid  and  the  mandible,  are  all  included  in  the 
bones  whose  disturbed  relationship  may  be  responsible  for  dis- 
turbed circulation  through  this  pharyngeal  area,  as  well  as  for 
disturbed  secretions. 

Without  discussing  whether  or  not  infection  of  the  normal 
mucous  membrane  occurs,  it  may  be  granted  that  the  danger  of 
infection  is  increased  by  those  agencies  which  interfere  with  the 
normal  circulation  of  the  blood,  and  the  normal  course  of  nerve 
impulses  through  the  governing  centers.  To  these  factors  must 
"be  added  those  which  lower  the  systemic  immunity,  such  as  the 
rigid  lower  thoracic  spinal  column,  various  disturbances  of  nutri- 
tion, and  the  effects  of  autogenous  or  extraneous  poisons. 

The  treatment  of  the  diseases  of  the  pharyngeal  region  con- 
sists chiefly  in  the  removal  of  the  factors  which  cause  or  perpetuate 
the  diseased  condition. 

194  * 


ACUTE  PHARYNGITIS  195 

ACUTE  PHARYNGITIS 

(Angina  catarrhalis;   sore  throat;   angina  simplex;   hyperemia;   edema  of  the 

uvula) 

An  acute  inflammation  of  the  pharynx  is  usually  associated  with 
varying-  degrees  of  laryngitis  and  tonsillitis.  The  trouble  begins  as 
an  acute  hyperemia,  which  may  terminate  in  recovery,  with  no 
further  symptoms,  may  go  on  to  serious  forms  of  pharyngitis,  or 
may  persist  as  a  chronic  hyperemia.  This  disturbance  is  an  im- 
portant cause  of  the  more  serious  inflammations,  and  permits  the 
infection  of  the  throat  by  bacteria  which  might  have  been  unable 
to  attack  a  throat  otherwise  normal. 

Hyperemia  of  the  pharynx  is  due  to  irritation  by  tobacco  smoke, 
constant  use  of  the  voice,  is  a  part  of  naso-pharyngeal  catarrh ; 
may  be  due  to  lesions  of  the  mandible,  upper  cervical  or  upper 
thoracic  region,  either  alone  or  associated  with  any  of  the  first- 
mentioned  causes. 

The  mucosa  is  reddened,  and  the  venules  may  show  distension. 
Distended  veins  may  be  due  to  valvular  heart  lesions  or  to  pres- 
sure upon  the  superior  vena  cava.  Hemorrhage  is  due  to  local 
causes,  usually  traumatic. 

Edema  of  the  uvula  is  not  uncommon  in  debilitated  condi- 
tions ;  in  milder  degree  it  may  be  associated  with  lesions  especially 
of  the  mandible,  less  frequently  the  upper  cervical  vertebrae.  The 
enlarged  uvula  may  irritate  the  throat  to  such  an  extent  as  to  cause 
chronic  hyperemia  or  even  tend  to  a  pharyngitis;  the  voice  may 
become  husky  as  the  result  of  the  laryngeal  involvement.  When 
the  edema  persists  an  overgrowth  of  tissue  may  occur ;  it  may  thus 
become  necessary  to  remove  the  superfluous  tissue  surgically. 

When  acute  hyperemia  persists,  or  as  a  result  of  exposure  to 
cold,  digestive  disturbances,  rheumatism  and  gout,  or  other  sources 
of  disturbance  of  mucous  secretion,  a  more  acute  inflammation 
of  the  pharynx  occurs.  Cervical  and  mandibular,  upper  rib  and 
clavicular  lesions  predispose  to  the  disease. 

Diagnosis.  The  trouble  begins  as  uneasiness  and  soreness  on 
swallowing,  a  feeling  of  tickling  and  dryness  in  the  throat,  a  desire 
to  hawk  and  spit,  and  stiffness  of  the  neck.  The  cervical  l3^mph 
glands  are  enlarged  and  painful.  The  process  may  extend  to  the 
Eustachian  tube,  producing  slight  deafness,  and  to  the  larynx  with 
hoarseness.  The  constitutional  symptoms  are  chilliness,  fever  of 
moderate  degree,  increased  pulse  rate,  cough,  and  more  or  less 
nasal  voice. 

Inspection  shows  a  general  dry,  red,  congested  condition  of 
the  whole  throat  with  edema  of  the  uvula.  The  tonsils  may  or 
may  not  become  involved.  The  cervical  muscles  are  irregularly 
contracted  and  painful  when  touched.    The  skin  over  the  neck  is 


196  THE  PHARYNX  AND  LARYNX 

often  hypersensitive.  The  secretion  is  thick,  tenacious  and  opaque. 
The  voice  is  usually  affected,  as  a  result  of  the  associated  laryn- 
gitis. 

Treatment.  "In  treating  pharyngeal  diseases,  I  first  adjust  the 
clavicles  at  both  ends.  I  also  adjust  all  of  the  ribs  of  each  side 
from  the  first  to  the  fifth.  Adjust  the  atlas  and  axis.  *  *  *  Then 
I  see  that  the  lower  ribs  from  the  eighth  to  the  twelfth  are  all  left 
in  a  normal  condition.  I  am  very  careful  to  have  a  normal  adjust- 
ment of  the  whole  lumbar  vertebrae." — A.  T.  Still. 

Muscular  contraction  anywhere  in  the  neck  or  upper  dorsal 
region  needs  relaxation  to  prevent  lesions  and  blood  stasis.  Espe- 
cially is  it  necessary  to  relax  around  the  hyoid  bone.  Careful 
treatment  of  the  upper  cervical  lymphatics  is  effective.  The  diet 
should  be  liquid  if  there  is  much  fever,  or  if  solid  food  causes  much 
irritation.  As  a  gargle  or  a  pharyngeal  douche,  a  normal  saline  is 
Abetter  than  anything  else.  The  main  purpose  of  a  gargle  is  cleans- 
ing of  the  membrane  from  the  abnormal  and  irritating  secretions, 
which  often  contain  pathogenic  organisms. 

Prognosis.  Recovery  is  the  rule,  in  a  few  days  to  a  week  or 
more.  Each  attack  predisposes  to  later  attacks,  and  to  chronic 
pharyngitis. 

PHLEGMONOUS  PHARYNGITIS 

(Acute  inflammatory  phlegmon  of  the  pharynx;  retropharyngeal  abscess) 

These  diseases  are  practically  the  same  in  etiology,  diagnosis 
and  treatment,  whether  the  location  is  in  the  walls  of  the  pharynx 
or  in  the  posterior  sub-mucous  tissue. 

Etiology.  Primarily,  the  disease  is  due  to  pyogenic  micro- 
organisms. It  may  complicate  scarlet  fever,  diphtheria,  erysipelas, 
or  syphilis. 

Diagnosis.  The  disease  begins  with  sore  throat,  dysphagia 
and  hoarseness.  Fever,  dyspnea,  and  swelling  of  the  cervical 
lymphatics  are  associated  with  considerable  prostration.  The 
pharyngeal  mucosa  is  at  first  deep  red,  purple,  swollen,  tense, 
shiny  and  dry.  Vesicles  appear  and  the  secretion  becomes  profuse; 
suppuration  occurs  speedily.  The  pus  may  be  localized  or  may 
be  diffusely  scattered  through  the  membrane. 

The  muscles  of  the  neck,  mid-thoracic  region,  and  sometimes 
of  the  lumbar  region  are  contracted  and  hypersensitive. 

The  blood  shows  leucocytosis  in  variable  degree,  according  to 
the  severity  of  the  infection  and  the  strength  of  the  reaction  to  the 
invading  organisms. 

Treatment.  An  important  factor  in  promoting  the  resistance  to 
this,  as  to  any  infection,  is  to  increase  the  mobility  of  the  lower 


MEMBRANOUS  PHARYNGITIS  197 

thoracic  region — from  the  sixth  to  the  twelfth  thoracic,  with  the 
corresponding  ribs.  Manipulation  of  the  neck  is  difficult,  yet,  with 
care,  muscles  can  be  relaxed,  bony  and  other  lesions  corrected, 
venous  and  lymph  drainage  facilitated.  The  ribs  should  be  raised, 
the  clavicles  loosened,  if  they  are  found  depressed  or  associated 
with  tense  muscles ;  the  mandible  and  hyoid  freed  from  tension. 
All  treatment  must  be  carefully  based  upon  a  recognition  of  the 
pathological  changes  occurring  in  each  patient,  as  found  on  fre- 
quent examination. 

When  the  pus  accumulates  it  should  be  surgically  evacuated  at 
once.  Incision  must  be  made  as  indicated  by  the  location  of  the 
pus,  and  by  other  local  conditions.  While  there  is  little  doubt  that 
quite  large  collections  of  pus  can  be  absorbed  and  carried  away, 
sometimes  without  apparent  injury,  there  is  always  the  risk  of 
rupture,  with  infection  of  the  lungs  or  the  digestive  tract;  septi- 
cemia may  result  from  the  invasion  of  the  lymphatics  or  the  veins 
by  the  infectious  agent.  Spontaneous  evacuation  during  sleep  may 
result  in  suffocation.  The  clean  incision  under  ordinary  surgical 
precautions  with  evacuation  of  the  pus  is  much  less  dangerous. 

Prognosis.  With  correct  surgery  and  such  other  treatment  as 
is  indicated,  practically  all  patients  should  recover.  The  prognosis 
of  the  underlying  disease  is  to  be  considered ;  the  outlook  is  always 
somewhat  doubtful,  in  this  as  in  all  cases  with  pus  formation,  with 
the  possibility  of  septicemia. 

MEMBRANOUS  PHARYNGITIS 

(Croupous  pharyngitis) 
Membranous  pharyngitis  is  due  to  infection  by  diphtheria  (q.  v.)  or 
by  any  of  the  pyogenic  organisms,  rarely  the  pneumococcus  or  the  bacillus  coli 
communis;  usually  such  invasions  are  upon  pharyngeal  membranes  injured  by 
direct  trauma,  or  by  the  effects  of  circulatory  disturbances.  The  condition  may 
be  associated  with  scarlatina,  measles,  typhoid,  variola,  etc.  (q.  v.).  The  treat- 
ment is  that  of  the  primary  disease,  plus  the  treatment  of  catarrhal  or  phleg- 
monous pharyngitis, 

ANGINA  LUDOVICI 

(Ludwig's  angina;  cellulitis  of  the  neck) 

This  disease  is  not  very  frequent  in  this  country.  It  is  caused  by  strepto- 
coccic infection,  and  is  usually  secondary  to  diphtheria  or  scarlet  fever.  The 
process  is  attended  by  sw^elling  of  the  sub-maxillary  glands  of  one  side,  spreads 
to  the  floor  of  the  mouth,  and  to  the  front  of  the  neck.  The  parts  are  dusky- 
red  and  present  brawny  induration. 

Diagnosis.  The  symptoms  are  intense  with -much  pain.  Dysphagia,  diffi- 
cult mastication  and  articulation,  and  grave  dyspnea  may  supervene  from 
compression  or  edema  of  the  glottis. 

Treatment.  When  the  pus  does  not  accumulate,  the  treatment  should  be 
carefully  devoted  to  securing  better  circulation  through  the  infected  area.  So 
long  as  no  necrosis  occurs,  there  is  little  danger  of  septicemia  from  the  circu- 


198  THB  PHARYNX  AND  LARYNX 

lation  of  the  blood  through  the  infected  area;  when  the  pus  accumulates  and 
necrotic  tissues  are  present,  local  manipulation  should  be  limited  to  the  surgical 
evacuation  of  the  pus.  Throughout  the  disease,  the  ribs  should  be  freely  raised, 
reflex  muscular  contractions  corrected,  and  the  mobility  of  the  thoracic  region 
secured  by  treatment  as  frequently  given  as  may  be  necessary  to  secure  these 
results. 

VINCENTS  ANGINA 

This  form  is  due  to  the  bacillus  fusiformis  and  the  spirocheta  dentinum 
and  is  feebly  contagious.  There  is  superficial  ulceration  and  the  formation 
of  a  membrane,  usually  beginning  on  one  or  both  tonsils  and  spreading  to  other 
parts  of  the  pharynx. 

Treatment.  In  addition  to  the  corrective  work  advised  for  other  forms 
of  pharyngitis,  the  frequent  use  of  a  mild  gargle  is  helpful  and  comfortable. 

ULCERS  OF  THE  PHARYNX 

Follicular  ulcers  are  usually  small,  superficial,  and  generally  associated 
with  chronic  catarrh.  Syphilitic  ulcers  are  small,  shallow,  painless,  rounded, 
yellow  and  sloughy,  surrounded  by  a  reddened  zone,  and  appear  upon  the 
posterior  wall.  Typhoid  ulcers  are  small,  round  or  oval,  and  appear  toward 
the  close  of  an  attack  of  typhoid  fever.  Tuberculous  ulcers  have  irregular 
boundaries  and  a  yellowish-gray  floor,  are  intensely  painful,  and  also  appear 
upon  the  posterior  wall.  Cancerous  ulcers  have  the  usual  characteristics  of 
malignant  disease. 

The  treatment  of  these  is  constitutional  or  surgical.  Local  application  of 
1  to  10%  silver  nitrate  may  clear  up  non-cancerous  ulcers. 

CHRONIC  PHARYNGITIS 

(Clergyman's  sore  throat;  chronic  follicular  pharyngitis) 

This  is  a  disease  characterized  by  a  hu.sky  or  muffled  voice, 
and  a  tendency  to  clear  the  throat.  Speaking  becomes  difficult, 
and  the  throat  becomes  tired  when  speech  is  necessary. 

Etiology,  The  disease  follows  repeated  acute  attacks ;  improper 
or  excessive  use  of  the  voice,  especially  with  loud  tones ;  excessive 
use  of  alcohol  or  tobacco  or  naso-pharyngeal  catarrh.  Perhaps 
the  most  important  etiological  factor  is  the  presence  of  lesions  of 
the  third  cervical  ^or  its  neighbors,  or  of  the  occiput.  The  hyoid 
is  frequently  involved  through  muscular  contractions.  These 
lesions  themselves  tend  to  change  the  ease  of  vocalization ;  thus 
they  act  in  at  least  two  ways  in  the  etiology  of  the  disease. 

Diagnosis.  The  symptoms  and  history  are  fairly  patKognom- 
onic.  The  examination  of  the  throat  shows  the  characteristic 
granular  membrane. 

The  mucous  membrane  is  more  or  less  congested,  numerous 
distended  venules  are  seen,  and  the  secretion  is  mucoid,  muco- 
purulent, or  purulent.  Often  dry  scales  of  offensive  odor  are 
found.  Hyperplasia  of  the  lymph-follicles  forms  elongated  rows 
in  the  lateral  or  posterior  walls. 


ACUTE  LARYNGITIS  199 

Treatment.  The  correction  of  faulty  habits  of  speaking  is 
important.  Correction  of  the  bony  lesions  found  in  each  case  is 
usually  necessary  to  permanent  recovery.  A  gargle  of  normal  salt 
solution  or  of  boracic  acid  or  of  hot  water  gives  comfort  and 
cleans  the  roughened  membranes.  Condiments,  alcohol,  tobacco, 
should  be  discontinued.  Cauterization  and  astringents  are  dan- 
gerous and  rarely  give  any  relief.  The  scars  left  by  these  meth- 
ods are  often  very  annoying,  and  may  lead  to  serious  troubles  later. 

Prognosis.  In  early  cases  recovery  may  be  expected  within 
a  few  weeks.  The  time  necessary  for  recovery  depends  upon  the 
time  during  which  the  disease  has  been  present,  the  obedience  to 
the  instructions  concerning  the  use  of  the  voice,  to  a  correct  dietetic 
and  hygienic  regime,  and  to  the  possibility  of  securing  permanent 
correction  of  the  lesions  as  found.  There  is  a  tendency  to  recur- 
rence if  the  lesions  recur,  or  if  the  voice  is  used  improperly,  or 
if  the  tobacco,  alcohol,  or  other  irritating  factors  are  resumed. 


ATROPHIC  PHARYNGITIS 

(Pharyngitis  sicca)  .     • 

In  this  type  the  secretion  is  scanty,  the  mucous  membrane  is  reddish-browr 
in  color,  thin,  smooth  and  shiny. 

Diagnosis.  There  is  a  constant  desire  to  hawk  and  spit,  with  a  dropping 
of  mucus  from  the  upper  pharynx,  sHght  redness  increased  from  various  causes 
at  times.  On  inspection,  the  mucous  membrane  of  the  posterior  pharyngeal 
wall  is  seen  a  dusky-red  and  studded  with  the  elongated  lymph-follicles  or  is 
dry  and  glistening. 

Treatment.  The  patient  must  be  taught  correct  methods  of  phonation 
and  articulation;  the  lesions  as  found  must  be  corrected;  the  general  health 
must  be  kept  at  high  level.  Complete  rest  of  the  voice  may  be  found  necessary 
in  some  cases. 

Prognosis.  Recovery  is  slow.  It  is  not  dangerous  to  -life  and  may  be 
greatly  helped,  if  not  entirely  relieved,  by  long-continued,  persistent  treatment. 


ACUTE  CATARRHAL  LARYNGITIS 

(Acute  laryngitis;  sore  throat;  acute  endolaryngitis) 

Etiology.  Acute  laryngitis  may  be  caused  by  the  inhalation  of 
irritating  vapors  or  dust;  by  drinking  irritating  liquids;  by  over- 
use, or  improper  use  of  the  voice ;  or  by  extension  of  inflammation 
from  other  areas.  It  is  usually  associated  with  pharyngitis,  and 
often  with  tonsillitis  and  rhinitis.  It  often  occurs  during  the  course 
of  the  acute  infectious  fevers.  Contraction  of  muscles  and  subluxa- 
tions of  bones  in  the  cervical  and  upper  thoracic  areas,  are  impor- 
tant causes ;  comparatively  slight  irritants  cause  severe  inflamma- 
tions when  these  structural  perversions  are  already  present.  The 
hyoid  and  the  axis  are  most  often  concerned  in  these  cases.     The 


200  THB  PHARYNX  AND  LARYNX 

reflex  muscular  contractions  caused  by  the  irritant  perpetuate  the 
inflammation  in  many  cases. 

Diagnosis.  The  disease  usually  begins  rather  suddenly  with 
sensations  of  dryness,  pain  and  tickling  in  the  laryngeal  region, 
hoarseness  increasing  to  aphonia,  slight  fever,  painful  deglutition, 
and  a  dry,  noisy,  hoarse  cough.  The  laryngoscopic  examinations 
reveal  swelling  of  the  mucosa,  usually  most  marked  in  the  ary- 
epiglottidean  folds,  with  redness  and  swelling  of  the  true  vocal 
cords.  The  surface  may  be  covered  with  a  varying  amount  of 
mucus.     Sometimes  patches  of  erosion  are  found. 

Treatment.  Rest  in  bed,  and  absolute  rest  of  the  voice,  is  indi- 
cated. If  it  is  necessary,  the  patient  may  whisper  very  faintly,  but 
it  is  better  for  him  to  write  his  communications.  Inhalations  of 
steam,  the  ice  bag  to  the  neck,  a  cold  pack,  and  a  hot  water  bottle 
between  the  shoulders,  are  some  of  the  things  which  give  relief. 
Usually  an  accumulation  of  fecal  material  is  found  on  palpating 
the  colon;  this  should  be  removed  by  a  moderately  warm  enema. 

The  important  factors  in  treatment  are  the  relaxation  of  the 
reflex  muscular  contractions,  and  the  correction  of  whatever  other 
lesions  may  be  found.  Carefully  elevating  the  larynx  and  relaxing 
contiguous  tissues  are  beneficial.  Note  the  condition  of  the  first 
ribs.  It  may  not  be  advisable  to  do  the  corrective  work  until  the 
local  inflammation  has  begun  to  subside,  but  if  further  attacks  are 
to  be  prevented,  and  if  the  patient  is  to  recover  and  keep  his  voice, 
the  corrections  must  be  made.  One  or  two  treatments  each  day 
should  be  given,  until  the  acute  stage  has  passed ;  if  one  thorough 
treatment  is  given  at  the  beginning  of  the  attack  it  may  be  all  that 
is  needed.  But  the  complete  correction  of  structural  perversions 
must  not  be  neglected,  even  though  the  acute  symptoms  disappear 
completely,  with  or  without  palliative  treatment. 

Prognosis.  *  Most  cases  recover  in  one  or  two  days,  if  the  treat- 
ment is  given  on  the  first  appearance  of  the  symptoms.  Each  day 
of  delay  in  treatment  means  several  days  of  delay  in  recovery. 
Recurrent  attacks  are  to  be  expected,  if  the  lesions  remain  or  recur, 
or  if  the  irritating  agents  persist  or  reappear.  The  repeated  attacks 
lead  to  chronic  laryngitis,  (q.  v.) 

EDEMATOUS  LARYNGITIS 

(Edema  of  the  glottis) 

The  infiltration  of  the  tissues  of  the  larynx  and  glottis  may  be 
a  true  inflammatory  edema,  or  may  be  the  result  of  diseases  in 
other  organs. 

Etiology.  It  is  rather  more  frequent  in  chronic  laryngitis  than 
in  acute,  and  is  especially  frequent  in  acute  exacerbations  of  the 


CHRONIC  LARYNGITIS  201 

chronic  form.  Subacute  or  chronic  inflammations  are  often  asso- 
ciated with  edema — the  husky  voice  in  tubercular  or  syphilitic 
laryngitis  is  almost  pathognomonic. 

Noninflammatory  edema  occurs  in  angio-neurotic  edema,  which 
may  affect  the  glottis;  this  may  result  in  serious  or  even  fatal 
asphyxia.  Nephritis,  and  other  diseases  associated  with  edema, 
may  affect  the  larynx ;  edema  of  the  glottis  thus  produced  may  be 
serious. 

Diagnosis.  The  onset  varies  according  to  the  etiological  fac- 
tors. The  dyspnea  is  urgent;  dysphagia,  aphonia,  violent,  ineffec- 
tual cough,  stridulous  breathing,  and  weakness  are  some  of  the 
more  common  symptoms.  Death  from  asphyxia  may  occur  at 
any  time ;  sudden  death  without  premonitory  symptoms  may  occur. 

The  laryngoscopic  examination  shows  very  large,  semitrans- 
parent,  grayish  yellow  swellings,  which  involve  the  epiglottis  and 
the  true  and  false  vocal  cords. 

Treatment.  Vigorous  treatment  must  be  given  to  secure  rapid 
drainage  from  the  affected  tissues.  The  cervical  area  and  tissues 
around  epiglottis  must  be  relaxed  and  careful  attention  given  to 
the  upper  dorsal  vertebrae  and  ribs.  An  ice  bag  applied  over  the 
larynx  and  ice  in  the  mouth  are  good.  If  relief  is  not  speedily 
obtained,  tracheotomy  must  be  performed.  Adrenalin  spray  may 
give  temporary  relief. 

Prognosis.  About  half  the  cases  terminate  fatally.  Patients  are 
liable  to  die  from  exhaustion,  sepsis,  or  pulmonary  complications 
after  the  edema  is  removed.  The  duration  is  from  a  few  hours  to 
several  days.    Recovery  depends  upon  early  vigorous  treatment. 

CHRONIC   LARYNGITIS 

(Chronic  catarrhal  laryngitis;  chronic  endolaryngitis) 
Chronic  laryngitis  may  follow  repeated   attacks  of  the  acute 
form,  or  it  may  begin  insidiously,  and  be  chronic  from  the  first. 
It  is  often  associated  with  granular  pharyngitis. 

Etiology.  It  is  caused  by  the  usual  factors  concerned  in  acute 
laryngitis ;  these  may  be  mildly  irritating  through  a  long  time, 
thus  causing  the  chronic  type ;  other  causes  include  nasal  obstruc- 
tion and  mouth-breathing;  excessive  and  improper  use  of  the 
voice  (dysphonia  clericorum),  especially  in  the  open  air;  excessive 
inhalation  of  tobacco  smoke,  and  chronic  alcoholism. 

Diagnosis.  The  common  symptoms  are  constant  hawking  and 
a  desire  to  swallow;  expectoration  of  a  scanty  mucoid  or  muco- 
purulent material  or  of  small  glairy  balls  or  crusts;  attacks  of 
hoarseness  or  aphonia;  and  a  husky,  hoarse,  rough  voice.  Very 
little  pain  is  present.    The  general  health  is  not  affected.    Laryn- 


202     ^       THB  PHARYNX  AND  LARYNX 

goscopic  examination  shows  the  mucous  membrane  slightly  red- 
dened, perhaps  granular;  the  true  cords  grayish  or  slightly  injected. 

Treatment.  Remove  muscular  contractures,  and  correct  any 
bony  lesions  found,  particularly  those  of  the  atlas,  axis  and  third 
cervical  Vertebrae,  the  hyoid  and  the  clavicle  and  the  first  rib. 
Removal  of  the  cause  is  necessary.  If  the  condition  is  due  to 
overuse  of  the  voice,  rest  absolutely;  if  to  smoking  or  alcoholism, 
institute  treatment  to  remove  the  habit;  and  if  environmental  or 
personal  habits  are  faulty,  secure  their  removal  as  far  as  possible. 
Plenty  of  fresh  air,  sponging  the  neck  night  and  morning  with 
cold  water,  avoidance  of  wrapping  the  neck  too  much,  systematic 
throat  exercises,  and  education  in  the  use  of  the  voice  are  some 
of  the  factors  of  general  hygiene  necessary  in  these  cases. 

Prognosis.  Complete  recovery  is  not  common  owing  to  the 
persistence  of  causes  and  the  lack  of  cooperation  on  the  part  of 
the  patient.  If  more  favorable  circumstances  permit,  the  chances 
for  recovery  are  good  within  a  few  weeks. 


CROUPOUS  LARYNGITIS 

(Membranous  croup;  croup) 

This  disease  is  usually  diphtheria,  (q.  v.)  Occasionally  other 
pathogenic  organisms  cause  the  formation  of  a  false  membrane, 
which  usually  peels  off  easily,  without  injury  to  the  underlying 
mucous  membrane.  It  may  be  due  to  any  of  the  ordinary  infec- 
tions of  childhood,  and  may  accompany  measles,  scarlatina,  or  any 
of  the  exanthemata. 

Diagnosis.  Cultures  should  always  be  made;  diphtheria  is 
always  to  be  suspected.  The  diphtheritic  membrane  is  thick,  yel- 
low, tenacious,  with  necrotic  areas;  its  removal  leaves  an  injured, 
bleeding  surface.  The  membrane  due  to  other  organisms  is  usually 
thin,  bluish-white,  semitransparent,  and  its  removal  leaves  a  hyper- 
emic  but  intact  mucous  membrane.  The  membrane  may  be  puru- 
lent and  yellowish,  tenacious  and  thick,  when  the  infection  is  by 
the  more  virulent  pyogenic  organisms.  The  removal  of  such  a 
membrane  injures  the  underlying  mucous  membrane,  as  is  the  case 
in  the  true  diphtheritic  formation.  The  only  distinction  is  found 
in  the  results  of  the  culture  taken  from  the  throat,  which  is  not 
absolutely  reliable. 

The  symptoms  are  startling,  and  the  disease  is  sufficiently 
serious.  The  onset  is  either  sudden  with  an  attack  of  spasmodic 
croup  or  gradual  with  acute  catarrhal  laryngitis.  The  voice 
becomes  husky,  smothered,  whispering  or  suppressed ;  a  prodromal 
"croupy"  cough  for  a  day  or  so  becomes  hissing,  explosive  and 
metallic  during  the  attack;  difficulty  in  breathing  follows.     The 


SPASMODIC  CROUP  r    203 

child  is  unable  to  lie  down.  If  quiet  for  a  time,  he  starts  up 
in  fright,  breathing  heavily  with  a  shrill  inspiration.  Expiration 
becomes  difficult  and  noisy;  suflfocation  seems  imminent  from 
spasm  of  the  glottis.  Cyanosis,  profuse  perspiration,  and  symp- 
toms of  asphyxia  seem  about  to  terminate  in  death,  when  the 
spasm  ceases,  and  the  child  is  fairly  comfortable,  though  stupid 
for  a  time.  Portions  of  the  membrane  may  be  expelled  by  cough- 
ing, during  the  intermissions.  In  cases  tending  toward  recovery, 
the  appearance  of  improvement  is  maintained  between  attacks,  the 
paroxysms  become  less  frequent  and  severe ;  expectoration  of 
membrane  is  marked.    The  fever  lessens  and  disappears. 

In  those  cases  tending  toward  fatal  termination,  the  attacks 
become  more  frequent  and  severe ;  expectoration  is  absent ;  respira- 
tion is  more  frequent  and  shallow  without  whistling  and  stridor; 
stupor  and  insensibility  deepen,  and  the  child  dies  of  asphyxia. 

Treatment.  The  first  thing  is  the  relief  of  the  dyspnea.  Thor- 
ough relaxation  of  the  tissues  of  the  throat  and  neck  usually  give 
relief.  The  treatment  for  simple  croup,  especially  the  inhalation  of 
steam  from  boiling  w^ater  or  slaking  lime,  are  efficacious  in  pro- 
moting relaxation  of  the  spasmodic  muscles.  Hot  packs  to  the 
throat,  if  they  can  be  used,  are  good.  The  room  must  be  thor- 
oughly well  ventilated ;  the  perspiring  body  of  the  child  should  be 
protected  from  drafts.  A  hot  bath  may  be  employed ;  this  to  be  fol- 
lowed by  vigorous  rubbing  of  the  skin. 

During  the  intervals,  if  the  child  is  not  asleep,  washes  or  gargles 
very  soft  and  aseptic  are  good;  care  should  be  taken  to  avoid 
injury  to  the  mucous  membrane.  No  attempt  at  antisepsis  is  of 
any  avail,  but  the  washes  should  be  aseptic — should  carry  no  new 
germs  into  the  injured  throat.  Restricted  diet  or  none  is  permitted. 
Fruit  juices,  especially  pineapple  juice,  are  refreshing. 

A  child  with  any  sickness  should  be  kept  from  other  children, 
especially  is  this  true  wnth  fevers,  and  in  cases  which  bear  clinical 
resemblance  to  the  acute  infections,  even  though  the  actual  infec- 
tiousness cannot  be  demonstrated,  it  is  much  better  to  secure  as 
complete  isolation  as  possible. 

The  prognosis  is  doubtful  in  all  cases ;  most  patients  recover  in 
six  to  ten  days,  but  there  is  always  the  danger  of  asphyxia,  and 
of  more  extended  invasion  of  the  tissues  by  the  organism  con- 
cerned. 

SPASMODIC  CROUP 

(Including  spasmodic  laryngitis;  simple  croup;  false  or  pseudo  croup;  catarrhal 

croup;  laryngitis  with  spasm;  spasm  of  the  glottis;   Miller's,  or 

Kopp's,  or  thymic  asthma;  child-crowing;  tetanic  croup; 

laryngismus   stridulus) 

This  is  essentially  a  nervous  disturbance  with  symptoms  due 
to  the  spasmodic  tension  of  the  vocal  muscles,  with  closure  of  the 


204  THB  PHARYNX  AND  LARYNX 

larynx.  The  tension  is  often  present  in  membranous  laryngitis  and 
in  many  forms  of  acute  and  chronic  laryngitis,  pharyngitis,  and 
sometimes  tonsillitis,  rhinitis,  bronchitis,  and  pneumonia. 

Etiology.  The  patients  are  almost  always  children  of  neurotic 
make-up,  not  often  more  than  seven  or  eight  years  old,  rarely 
less  than  one  year.  Cases  have  been  reported  of  very  small  infants, 
and  of  adults  and  senile  patients.  Reflex  causes  include  worms, 
overeating,  irritating  and  improper  foods ;  chronic  tonsillitis,  and 
adenoids ;  bad  teeth ;  rachitis,  marasmus,  or  other  malnutrition ; 
exposure  to  sudden  cold,  or  to  dampness ;  emotional  storms,  frights, 
unwise  attempts  at  discipline,  an^  other  shocks  to  the  nervous 
centers. 

Diagnosis.  The  symptoms  vary  according  to  the  etiological 
factors.  Usually  it  is  of  sudden  nocturnal  onset;  the  child  is  well 
or  suffering  from  the  causal  condition,  sleeps  a  few  hours  and 
wakes  suddenly  with  a  metallic,  resonant  respiration  and  great 
dyspnea,  with  stridulous  inspirations  from  narrowing  of  the  glottis 
by  spasm,  and-  wheezy  stridulous  expirations  ending  with  a  high- 
pitched,  inspiratory  crowing  sound  on  relaxation  of  the  spasm. 

In  severe  cases  all  the  accessory  respiratory  muscles  are  called 
into  action  during  the  attack.  The  lips  and  nails  are  blue,  the 
surface  cold,  the  countenance  anxious,  the  inferior  portion  of  the 
chest  drawn  in  instead  of  expanded  during  inspiration,  and  there 
may  be  carpopedal  spasms.  General  convulsions,  strabismus,  and 
involuntary  discharge  of  feces  and  urine  sometimes  occur. 

The  attack  lasts  from  a  few  minutes  to  an  hour  or  more,  and 
may  return  after  a  few  hours'  sleep  or  on  the  following  night. 
During  the  day  there  may  be  a  slight  cough.  There  is  little  or 
no  fever  or  hoarseness.  It  often  recurs  at  the  same  hour  on  suc- 
cessive nights. 

Treatment.  To  relieve  the  spasm,  treat  the  upper  part  of  the 
chest  and  diaphragm,  especially  through  the  phrenic  nerve  and  its 
spinal  relations,  third  to  fifth  cervical,  and  treat  the  eighth  to  tenth 
ribs  anteriorly.     Correct  any  subluxations  found. 

A  hot  bath,  with  cold  sponging  to  the  chest  and  back,  is  a  good 
emergency  measure.  This  may  be  repeated  if  the  spasms  are  per- 
sistent. The  air  of  the  room  is  best  kept  moist  by  steam  from 
boiling  water.  Emesis  may  be  produced  by  tickling  the  fauces  with 
the  finger.  This  often  relieves  the  spasm  very  quickly.  After  an 
attack,  the  general  health  and  diet  must  be  regulated.  Any  irri- 
tating environmental  condition,  or  personal  habits,  must  be 
attended  to  promptly. 

The  prognosis  is  favorable  for  recovery.  Death  rarely  occurs 
during  the  paroxysm  in  very  young  or  debilitated  children. 


CHAPTER  XXI 
DISEASES  OF  THE  BRONCHI 

ACUTE  BRONCHITIS 

(Acute  bronchial  catarrh;  tracheo-bronchitis) 

Acute  bronchitis  is  an  acute  catarrhal  inflammation  of  the 
larger  and  middle-sized  bronchi,  occurring  at  all  ages,  but  par- 
ticularly at  the  extremes  of  life,  characterized  by  slight  febrile 
reaction,  substernal  pain,  cough  and  expectoration. 

Etiology.  Among  the  predisposing  causes  are  insufficient  food 
and  improper  clothing;  excessive  confinement  in  warm  rooms; 
subluxations  of  vertebrae  from  occiput  to  seventh  dorsal,  of  the 
ribs  from  first  to  sixth,  and  the  clavicle;  and  interscapular  and 
anterior  thoracic  muscular  contractions. 

Among  the  exciting  causes  are  exposure  to  cold  or  wet,  recur- 
ring rhinitis,  certain  infectious  diseases,  inhalation  of  irritant  vapors 
and  dusts,  and  many  micro-organisms  among  which  are  pyogenic 
cocci,  pneumococcus,  and  micrococcus  catarrhalis. 

Diagnosis.  The  condition  is  usually  ushered  In  with  nasal  or 
laryngeal  catarrh  or  both,  chilliness  with  aching  pain  in  the  limbs, 
joints,  and  trunk,  a  sense  of  constriction  about  the  chest,  pain  of  a 
raw,  burning,  tearing  character  behind  the  sternum  aggravated  by 
deep  inspiration  or  coughing,  a  sense  of  languor  and  weariness  out 
of  proportion  to  the  fever. 

At  first,  the  cough  is  hard  and  dry  with  little  expectoration;  in 
a  day  or  so  it  becomes  looser  and  the  sputum  more  abundant.  The 
breathing  is  embarrassed,  noisy  or  whistling.  The  temperature 
is  not  high,  100°  to  103°  F.,  but  the  skin  is  moist ;  the  pulse  accel- 
erated according  to  the  fever.  The  more  acute  symptoms  subside 
in  a  week  or  so  according  to  severity  and  convalescence  becomes 
slowly  established. 

Bronchial  fremitus  may  be  felt  in  thin  chests.  Percussion  gives 
a  clear  resonance  except  when  broncho-pneumonia  and  atelectasis 
complicate ;  hence  the  chest  should  be  examined  daily.  During  the 
first  stage,  there  is  harsh  breathing  with  bilateral  diffuse,  piping, 
sibilant,  or  sonorous  rales  which  are  shifting  and  affected  by  cough- 
ing. After  a  few  days,  the  breathing  is  puerile  with  prolonged 
expiration,  profuse  moist  bubbling  rales.  Breath  sounds  are  sup- 
pressed over  collapsed  areas  if  a  portion  of  the  tube  becomes 
plugged  with  secretion. 

205 


206  THE  BRONCHI 

Increased  respipatory  rate,  cyanosis  and  dyspnea  indicate  involv- 
ment  of  small  tubes,  or  bronchiolitis. 

Urine  is  febrile,  of  the  ordinary  type. 

The  sputum  during  the  first  two  days  is  almost  pure  mucin,  is 
tenacious,  viscid,  frothy,  and  transparent.  It  contains  a  few  leu- 
cocytes and  red  blood  cells,  few  ciliated  cells,  a  few  mononuclear 
leucocytes,  and  a  few  myelin  drops  of  the  simpler  types.  After 
this,  the  cough  loosens,  the  sputum  is  increased  in  amount,  is  less 
viscid  and  tenacious,  frothy,  with  whitish  and  sometimes  bloody 
stieaks.  This  is  followed  by  muco-purulent  secretion  of  nearly 
uniform  yellow  color,  containing  many  pus  cells.  Later,  it  becomes 
almost  purely  purulent,  100  to  200  cc.  daily ;  contains  much  myelin ; 
cells  mainly  polymorphonuclears  and  fat  in  large  masses. 

Treatment.  Most  cases  yield  without  treatment  if  patient  will 
take  a  hot  foot  or  full  tub. bath  and  go  to  bed  after  freeing  the 
bowels,  though  time  can  usually  be  saved  the  patient  by  following 
with  a  thorough  general  treatment  with  special  attention  to  the 
upper  respiratory  areas  until  a  definite  reaction  is  secured.  If  the 
disease  pereists,  relax  the  muscles  of  the  spine  and  chest,  raise 
the  ribs,  correct  any  subluxations  found,  secure  free  elimination 
by  bowels  and  kidneys.  The  room-air  is  best  kept  moist,  the 
patient  in  bed,  plenty  of  water  administered,  acidulated  with  lemon 
juice  if  preferred,  and  a  liquid  diet  prescribed  for  a  few  days. 
Treat  once  or  twice  each  day  until  acute  stage  passes. 

The  prognosis  is  favorable  for  recovery  within  a  few  days  or 
weeks.  In  young  children  and  the  aged,  the  course  is  more  pro- 
tracted, the  symptoms  more  severe,  and  complications  are  more 
apt  to  occur,  but  recovery  is  the  rule.  The  very  aged  and  the 
feeble  may  rarely  succumb,  or  chronic  bronchitis  supervene. 

CHRONIC  BRONCHITIS 

(Chronic  bronchial  catarrh;  secondary  bronchitis;  "winter  cough") 

Chronic  bronchitis  is  an  inflammation  of  long  duration,  affect- 
ing the  larger  and  middle-sized  bronchi,  very  common  in  the 
elderly  and  associated  with  chronic  cardiac,  pulmonary,  and  renal 
diseases,  characterized  by  cough  with  no  change  in  the  general 
health. 

Etiology.  The  chronic  follows  repeated  attacks  of  acute  bron- 
chitis; occurs  as  an  occupational  disease  among  those  working  in 
much  dust  and  smoke  and  in  irritating  vapors,  in  gout  and  rheu- 
matism and  in  the  chronic  cardiac,  pulmonary  and  renal  cases. 

Diagnosis.  There  is  cough  of  a  paroxysmal  nature,  often  more 
troublesome  at  night  and  in  the  morning,  with  either  scanty  or 
copious   expectoration   depending  upon   the   variety.     Sometimes 


CHRONIC  BRONCHITIS  2Q7 

shortness  of  breath  is  noticed  upon  exertion.  The  condition  does 
not  usually  impair  the  general  health  except  during-  acute  exacer- 
bations. There  are  usually  some  associated  structural  changes  as 
emphysema,  or  bronchiectasis. 

Many  cases  are  associated  with  chronic  catarrhal  gastritis.  The 
cough  is  often  absent  in  the  summer. 

There  are  four  general  varieties. 

Mucous  Catarrh  is  the  most  common  during  the  winter,  and  marked 
by  more  or  less  violent  paroxysms  of  coughing  and  the  expectoration  of  yellow- 
ish mucus. 

Dry  Catarrh  has  a  harsh,  distressing  cough  with  a  feeling  of  sore- 
ness or  rawness  under  the  sternum,  and  the  expectoration  of  small  globular 
masses.  This  occurs  particularly  when  associated  with  emphysema,  gout,  rheu- 
matism, or  asthma. 

Bronchorrhea  is  associated  with  bronchial  dilatation,  occurring 
most  commonly  in  the  elderly  and  marked  by  severe  coughing,  followed  by 
copious  expectoration  of  greenish-yellow,  often  fetid  mucus  (four  to  six  pints 
in  twenty- four  hours). 

Fetid  Bronchitis  is  often  associated  with  bronchiectasis  and  marked  by 
excessively  fetid  odor  of  breath  and  sputum.  The  decomposition  of  the  secre- 
tion within  the  bronchi  may  cause  gangrene  of  the  mucosa,  or  even  of  the 
lung  itself. 

Percussion  is  normal  in  simple,  uncomplicated  cases.  If  bron- 
chiectasis is  present,  then  there  are  diffused  spots  of  amphoric  or 
tympanitic  sound.  If  emphysema  is  associated,  there  is  hyper-reso- 
nance. 

The  respiratory  murmur  is  roughened,  harsh,  less  intense  than 
normal,  with  expiration  prolonged  and  forcible  or  wheezy.  There 
are  diffuse,  bilateral,  sonorous,  sibilant  or  moist  rales  of  all  sizes, 
often  crepitant  at  the  bases,  depending  upon  the  amount  of  secre- 
tion. If  dilatation  is  associated,  there  is  broncho-cavernous  breath- 
ing, with  large  and  small  gurgling  rales.  If  emphysema  is  present, 
the  sounds  are  modified  according  to  the  extent. 

Subluxations  are  present  from  the  occiput  to  the  sacrum. 
Among  the  commoner  ones  found  are  atlas,  axis,  third  cervical, 
second  to  fifth  dorsal  vertebrse,  first  rib  and  clavicular  luxations, 
curves  anterior  or  posterior  of  the  upper  dorsal  area  and  contrac- 
tions of  the  deep  spinal  muscles. 

Urine  may  be  highly  acid  and  slightly  albuminous  in  those 
cases  with  a  decided  acidemia.  In  chronic  bronchitis  always  exam- 
ine the  urine  on  account  of  the  liability  of  a  primary  kidney  con- 
dition. 

Sputum.  In  some  cases  is  a  very  small  amount  of  tenacious 
yellowish  viscid  mucus;  in  others  a  white  sticky  mucus.  In  the 
chronic  cases,  the  amount  is  more  abundant,  yellowish,  muco- 
purulent, separates  into  three  layers,  a  mucous  layer,  brownish- 
gray  serum,  and  a  muco-purulent  sediment. 


208  THE  BRONCHI 

In  fetid  bronchitis,  the  sputum  is  usually  thin,  grayish-white, 
separating  into  layers;  the  upper  is  covered  by  a  frothy  mucus, 
and  the  lower  is  a  thick  sediment  where  may  be  found  pea-sized 
gray  or  yellow  masses — Dittrich's  plugs,  bacteria,  pus,  leptothrix, 
and  fatty  acid  crystals. 

Treatment.  A  careful  examination  is  necessary  to  determine 
whether  there  is  an  underlying  organic  disease.  Relaxation  of  all 
contracted  muscles  and  correction  of  the  lesions  found  is  of  first 
importance ;  and  the  eliminative  organs  should  be  kept  active.  The 
general  hygiene  is  important  and  must  be  carefully  supervised. 
The  clothing  should  be  sufficient  but  not  too  warm.  Room  tem- 
peratures should  be  kept  even. 

The  diet  should  be  liberal,  nutritious,  and  mixed,  including 
plenty  of  water,  fresh  vegetables,  and  fruits. 

Instruction  in  breathing  and  exercises  to  strengthen  the  chest 
muscles  are  important  in  the  younger  patients.  A  change  to  a 
warm  climate  for  the  winter  is  often  beneficial. 

The  prognosis  is  never  dangerous  to  life  unless  associated  with 
other  diseases. 

FIBRINOUS  BRONCHITIS 

(Chronic  idiopathic  bronchitis;  membranous,  croupous,  diphtheritic  or  plastic 

bronchitis) 

Fibrinous  bronchitis  is  an  inflammation,  usually  chronic,  marked 
by  paroxysmal  cough,  difficult  breathing,  and  the  expectoration  of 
fibrinous  casts  of  the  larger  and  middle-sized  bronchi. 

Etiology.  The  direct  cause  is  unknown.  It  is  associated  with 
asthma,  emphysema,  typhoid  fever  and  tuberculosis,  and  is  usually 
a  disease  of  adults. 

Diagnosis.  The  symptomatology  is  not  different  from  the 
catarrhal  forms,  until  the  expectoration  of  the  false  membrane.  A 
violent  paroxysm  of  coughing  precedes  or  accompanies  the  expec- 
toration which  relieves  the  dyspnea.  After  more  or  less  of  the 
membrane  has  been  raised,  a  muco-purulent,  blood-stained  sputum 
is  present  for  several  days.    There  may  be  a  slight  febrile  reaction. 

There  are  acute,  subacute  and  chronic  forms,  the  attacks 
recurring  at  intervals  of  days,  weeks  or  years,  the  same  bronchus 
being  involved  each  time. 

There  is  diminished  fremitus  and  lessened  respiratory  murmur 
over  the  portions  of  lung  supplied  by  the  obstructed  tube.  When 
the  casts  are  dislodged,  the  murmur  becomes  slightly  roughened. 
In  the  unaffected  portions  of  lung  the  sounds  are  normal.  If  col- 
lapse of  the  lung  follows,  there  is  dullness.  The  upper  portions 
of  the  lungs  are  the  oftener  affected. 

Spine.    See  chronic  bronchitis.  •* 


BRONCHIECTASIS  209 

The  sputum  is  mucus,  the  casts  being  rolled  up  and  mixed  with 
it,  but  the  true  nature  is  shown  when  the  sputum  is  shaken  in 
water,  appearing  as  little  tubes,  from  the  size  of  a  bodkin  to  almost 
as  large  as  the  finger.  The  larger  ones  are  hollow  and  the  smaller, 
solid,  with  a  tree-like  appearance.  They  are  nearly  structureless, 
of  fibrillated  base  with  pus  and  mucous  corpuscles,  a  few  gland 
cells,  occasionally  a  blood  cell  in  the  outer  layers,  many  eosinophilic 
cells ;  Charcot-Leyden  crystals  and  Curschmann's  spirals  are  some- 
times present.  Instead  of  the  definite  casts,  there  may  be  shreds, 
lumps,  or  patches  of  membrane. 

The  treatment  is  that  of  chronic  bronchitis.  The  vapor  from 
alkaline  solutions  seems  to  help  dislodge  the  casts. 

The  prognosis  is  favorable  if  not  associated  with  tuberculosis, 
pneumonia,  or  emphysema.  In  young  children  it  not  infrequently 
proves  fatal. 

BRONCHIECTASIS 

(Dilatation  of  the  bronchi) 
Bronchiectasis  occurs  primarily  from  traumatism  or,  second- 
arily, from  chronic  pulmonary  conditions  whereby  the  walls  of 
the  bronchi  dilate  so  that  sacs  are  produced,  and  clinically  marked 
by  cough  and  abundant  expectoration. 

Etiology  and  pathology.  In  the  secondary  form,  contraction  of 
the  supporting  lung  tissue  causes  the  walls  to  yield  from  lack  of 
support.  The  cylindrical  form  is  often  produced  by  violent  cough- 
ing. Until  the  cavity  is  infected,  the  membrane  lining  the  cavity 
is  smooth  with  very  thin  walls.  It  is  much  more  frequent  in  the 
lower  lobes  than  in  the  upper.  The  condition  very  frequently 
follows  an  attack  of  "grippe."  It  may  be  widespread  or  a  single 
cavity. 

Diagnosis.  The  cough  is  usually  absent  during  the  day,  occur- 
ring mainly  in  the  morning.  The  mode  of  expectoration  is  char- 
acteristic, the  patient  usually  raising  an  enormous  quantity  of 
greenish-yellow  sputum  in  the  morning  upon  arising,  or  upon  aris- 
ing from  the  recumbent  position.  If  a  single  large  dilatation  occurs, 
there  are  the  physical  signs  of  cavity. 

When  diflfuse,  the  physical  signs  are  those  of  the  causative  dis- 
ease, usually  tuberculosis.  Fatal  hemorrhage  may  occur  from  rup- 
ture of  an  aneurysm  in  the  wall  of  the  cavity. 

The  physical  signs  disappear  as  the  cavity  fills  with  secretion, 
to  reappear  upon  coughing  and  expectoration.  These  are  tympany, 
cracked-pot  sound,  bronchial  breathing,  with  rales,  bronchophony, 
and  increased  vocal  fremitus.  The  sputum  is  a  grayish-brown,  or 
greenish-yellow  color,  separating  into  a  brownish  frothy  top,  a  thin 
mucoid  zone,  and  a  sediment  of  almost  pure  pus,  showing,  micro- 
scopically, pus  cells,  epithelial  debris,  large  fatty  acid  crystals; 


210  THE  BRONCHI 

sometimes  cholesterin  occurs ;  valerianic  and  butyric  acids  and  H'S 
produce  the  horrible  odor.  Cerebral  abscess  is  a  very  frequent 
complication. 

Treatment.     Is  that  of  the  primary  condition,  or  if  itself  pri- 
mary, that  of  chronic  bronchitis. 

Prognosis.    It  is  incurable  but  has  a  protracted  course.     The 
acute  form  is  unfavorable. 


BRONCHIAL  ASTHMA 

(Spasmodic  asthma) 

Bronchial  asthma  is  a  neurosis  marked  by  paroxysms  of  ex- 
piratory dyspnea  during  which  all  the  accessory  respiratory  mus- 
cles are  used;  the  diaphragm  is  fixed  and  there  is  a  peculiar  loud 
noisy  wheezing. 

Etiology.  It -often  occurs  in  neurotic  families;  may  be  a  result 
of  bronchial  irritation,  direct  or  indirect,  through  the  blood  or 
nervous  system ;  in  children  it  occurs  from  imperfect-  recovery 
from  naso-pharyngeal  conditions,  measles,  whooping-cough,  or 
capillary  bronchitis. 

There  are  three  main  theories  of  its  formation:  That  it  is  a 
neurogenic  spasm  of  the  involuntary  bronchial  muscles;  a  hyper- 
emia with  swelling  of  the  mucous  membrane ;  an  inflammation  of 
the  smaller  bronchioles.    Acidosis  is  also  to  be  considered. 

"The  etiological  factors  found  vary  considerably,  and  include: 

"Contraction  of  the  cervical  muscles,  probably  due  to  lesions  of  cervical 
vertebrae  and  exerting  irritation  to  the  trunk  of  the  vagus; 

"Pleuritic  adhesions; 

"Lesions  of  the  first,  second  and  third  thoracic  vertebrae,  with  slightly  ap- 
proximated ribs; 

"Reflex  effects  from  distant  organs  include :  eye-strain ;  contracted  sphincter 
ani,  itself  apparently  due  to  anterior  coccyx;  scar  tissue  in  cervix  uteri;  nasal 
polyps ;  cardiac  disturbances,  especially  functional ;  gastrectasis  and  other  con- 
ditions with  accumulations  of  gas." — P.  C.  O.  Clinic  Reports. 

Diagnosis.  There  may  be  premonitory  symptoms  as  coryza, 
bronchial  irritation,  thoracic  constriction,  gastric  disturbance,  de- 
pressing emotions  or  worry,  or  the  passage  of  a  quantity  of  pale 
limpid  urine. 

The  Attack.  During  the  night,  the  patient  awakens  in  great 
distress,  feels  as  if  there  were  no  air  in  the  room ;  assumes  a  char- 
acteristic attitude  grasping  some  support ;  fixes  the  shoulder  girdle 
and  uses  all  the  accessory  respiratory  muscles.  Expiration  is  pro- 
longed and  accompanied  by  a  peculiar  loud  noisy  piping  or  wheez- 
ing. The  face  is  flushed  or  cyanosed,  covered  with  sweat,  and  the 
neck  muscles  are  prominent ;  inspiration  is  short ;  respiration  is  not 
accelerated,  and  little  air  enters  the  lungs.    A  paroxysm  of  coughing 


ASTHMA  211 

and  expectoration  gives  relief,  and  may  even  terminate  the  dyspnea ; 
sleep  intervenes,  or  a  slight  lull  occurs  before  another  paroxysm. 
The  dyspneic  attack  may  last  for  an  hour  or  be  prolonged,  with 
more  or  less  severity,  for  several  days.  The  patient  is  left  more  or 
less  exhausted  and  with  a  cough  for  several  days.  During  the 
attack  the  thorax  is  expanded  and  fixed ;  the  diaphragm  only 
slightly  moves ;  the  spinal  muscles  are  rigid ;  inspiration  is  short 
and  expiration  is  prolonged;  the  face  pale,  anxious  in  expression; 
speech  is  impossible,  and  later,  the  face  is  covered  with  perspira- 
tion. Dry,  loud,  wheezing,  whistling,  sibilant  and  sonorous  rales 
are  heard  on  expiration ;  later,  bubbling  rales  and  vesicular  breath-  ' 
ing,  when  the  air  enters  more  freely.  During  the  height  of  the 
attack,  vesicular  breathing  is  hidden  under  the  louder  sounds. 

Percussion  shows  a  marked  hyper-resonance  over  both  lungs, 
due  to  an  acute  emphysema,  or  a  vesiculo-tympanitic  note  (band- 
box tone  of  Bamberger).  Cardiac  and  hepatic  dullness  are  dimin- 
ished but  return  to  normal  at  end  of  attack.  After  many  recur- 
rences, the  condition  tends  to  merge  into  a  permanent  and  chronic 
emphysema. 

During  the  intervals  there  are  the  usual  signs  of  bronchitis,  or 
very  little  change  from  normal. 

Subluxations  are  apt  to  be  found  from  the  occiput  to  the  coccyx 
but  those  of  the  third  to  fifth  cervical,  second  to  fifth  dorsal,  and 
of  ninth  and  tenth  dorsal  are  particularly  common.  During  the 
attack  the  whole  spinal  musculature  is  firmly  contracted.  There 
are  changes  in  the  natural  curves  of  the  spine,  asthmatic  hump- 
back, a  posterior  condition  of  the  lower  neck  and  the  upper  dorsal 
is  frequent,  or  there  are  irregular  short  curves,  the  whole  spine 
being  stiff  and  the  chest  nearly  immovable. 

The  blood  shows  a  great  increase  in  the  eosinophilic  leucocytes, 
often  to  20%  of  the  actual  leucocyte  count.  Very  high  eosinophile 
counts  are  reported.  The  blood  pressure  is  generally  reduced. 
The  sputum  is  expelled  with  difficulty  and  is  distinctive,  consisting 
of  ball-like  gelatinous  masses  (pearls  of  Lasnnac),  which  can  be 
unfolded  and  found  to  be  casts  of  the  small  bronchioles;  contains 
Curschmann's  spirals  of  two  sorts,  one  of  spiral  threads  with 
eosinophilic  leucocytes  entangled  in  the  meshes,  and  the  second 
with  a  clear  central  filament  surrounded  by  a  spiral  network  of 
strands  of  mucus.  Later  in  the  condition,  the  filaments  are  replaced 
by  octahedral  phosphatic  crystals  (Charcot-Leyden  crystals)  in  the 
now  muco-purulent  sputum. 

Treatment.     In  a  few  cases,  adjustment  of  the  upper  thoracic    • 
vertebrae  and  related  ribs  gives  permanent  relief,  especially  when 
this  is  done  during  the  intervals  of  the  attack.     Occasionally  the 
same  work  done  during  an  attack  gives  immediate  and  permanent 
rehef. 


212  THE  BRONCHI 

"During  the  attack,  raising  the  first,  second  and  third  ribs  may  give  relief." 
— Meacham. 

"Heavy  movements,  springing  the  spinal  column  generally,  and  raising  the 
ribs,  freeing  the  neck  structures,  with  the  patient  first  upon  the  side,  then 
upon  a  stool,  gives  immediate  relief." — S.  C.  Edmiston. 

In  the  intervals,  the  general  health  must  be  built  up  by  nutri- 
tious, easily  digested  foods,  the  personal  habits  regulated  if  neces- 
sary. It  is  often  necessary  to  teach  the  patient  a  more  rational 
view  of  life  and  its  accidents  so  as  to  prevent  emotional  storms. 

Prognosis.  The  disease  may  be  intractable.  Recovery  is  more 
frequent  under  osteopathic  care;  the  paroxyt-ms  are  relieved  more 
quickly  and  the  patient  does  not  have  to  recover  from  the  effect 
of  drugs.    Death  seldom  occurs  from  pure  asthma. 

Sequelae.  The  condition  results  in  emphysema  of  greater  or  less 
degree,  dilatation  of  the  right  heart  with  subsequent  dropsy, 
chronic  bronchitis,  or  cerebral  embolism.  Sequelae  are  best  pre- 
vented by  early  attention  to  the  asthma  and,  if  possible,  its  perma- 
nent relief. 

BRONCHO-PNEUMONIA 

(Catarrhal   pneumonia;   lobular   pneumonia;    capillary   bronchitis;    suffocative 

catarrh) 

Brorcho-pneumonia  is  an  acute  catarrhal  inflammation,  affect- 
ing the  extremes  of  life,  limited  to  the  mucosa  of  the  smaller  and 
terminal  bronchial  tubes  or  bronchioles,  and  the  alveoli,  caused  by 
the  pneumococcus,  bacillus  tuberculosis,  or  a  mixed  infection ; 
characterized  by  fever,  impeded  and  increased  respiration,  impeded 
circulation,  short  cough,  scanty  expectoration,  symptoms  of  non- 
aeration  of  the  blood,  and  great  depression.  Both  lungs  are 
affected. 

Etiology.  It  often  occurs  as  an  extension  of  bronchitis  and 
infection  by  a  mixed  bacterial  flora;  follows  the  infectious  fevers, 
particularly  measles,  pertussis,  and  influenza;  attacks  those  suffer- 
ing from  tuberculosis,  rickets,  and  other  debilitating  diseases;  and 
may  be  an  infection  by  the  bacillus  of  tuberculosis. 

An  acute  primary  form  attacks  children  under  two  years  in 
good  health,  and  is  probably  a  pneumococcus  infection.  There  are 
aspiration  and  deglutition  forms,  and  it  also  occurs  after  ether 
anesthesia. 

Diagnosis.  It  is  usually  preceded  by  a  mild  bronchitis,  the  onset 
being  gradual  with  chilliness  or  chills,  rise  of  temperature  102°  to 
104°  F.  of  a  typical  remittent  character;  the  pulse  rate  increased, 
100  to  120  per  minute,  somewhat  compressible;  the  skin  is  hot, 
the  face  flushed,  the  head,  neck,  and  upper  part  of  the  body  may 
be  covered  with  perspiration.  The  breathing  becomes  rapid,  40  to 
80  per  minute,  shallow,  and  difficult  with   an  expiratory  moan, 


BRONCHO-PNEUMONIA  213 

dilating  alae  nasi,  and  use  of  the  accessory  muscles.  Inspiration 
may  be  easy  or  difficult  but  is  always  imperfect.  There  is  a  pro- 
gressive dyspnea  with  orthopnea,  followed  by  the  onset  of  cyano- 
sis, with  inspiratory  retraction  of  the  base  of  the  sternum  and  lower 
costal  cartilages.  The  cough  is  dry,  short,  hacking,  painful,  and 
soon  followed  by  more  or  less  copious  muco-purulent  expectora- 
tion. Occasionally  in  children,  the  symptoms  are  predominently 
gastro-intestinal  or  cerebral. 

As  the  cyanosis  develops,  the  pulse  becomes  feeble  and  flicker- 
ing ;  the  cough  is  slight  and  suppressed ;  general  venous  congestion 
is  indicated  by  the  livid  countenance ;  lips  and  nails,  blue ;  surface, 
cold  and  often  covered  with  a  clammy  perspiration ;  the  mind,  dull. 
In  children,  stupor  and  convulsions  rapidly  supervene.  The  ex- 
pectoration is  scanty,  viscid,  and  difficult  to  raise ;  the  little  patient 
usually  swallowing  what  sputum  it  does  raise;  or  it  almost  ceases. 
Death  follows  from  apnea  and  depression. 

The  unfavorable  symptoms  are  pale  and  livid  countenance, 
bluish  lips,  dull  eyes,  restlessness  giving  place  to  apathy  and  a 
progressively  increasing  somnolence.  Defervescence  is  by  lysis 
and  is  rapid,  although  several  weeks  may  elapse  before  complete 
recovery.  The  duration  is  from  one  to  three  weeks ;  rarely  to  three 
months. 

Suppuration  and  gangrene  often  follow  the  aspiration  and  deglu- 
tition forms.  A  fibroid  change  is  the  common  termination  when  the 
causal  agent  is  the  bacillus  tuberculosis. 

Increased  vocal  fremitus  is  present  if  large  areas  are  involved. 
The  intervening  healthy  lung  gives  a  more  or  less  hollow  or  tym- 
panic note ;  there  is  increased  resistance ;  when  portions  of  lung 
are  collapsed,  there  are  circumscribed  areas  of  dullness,  these  being 
sometimes  shifting.  The  changes  are  most  marked  in  the  lower 
lobes  posteriorly,  and  there  may  be  compensatory  emphysema  in 
the  upper  lobes.  During  the  first  part  of  the  disease,  there  is  a 
feeble,  high-pitched  respiratory  murmur  which  becomes  distant  and 
harsh  as  the  disease  progresses,  or  there  may  be  a  diffuse,  or  basic 
vesiculo-bronchial  breathing.  Expiration  is  lengthened,  jerky, 
harsh  and  grunting.  Persistent  subcrepitant  double  rales  are  heard 
over  limited  areas,  particularly  on  either  side  of  the  spine,  followed 
in  severe  cases  by  large  mucous  rales.  There  may  be  undefined 
mucous  clicks  on  forced  inspiration.  Sometimes  there  are  patches 
of  tubular  breathing.  VocaP  resonance  is  increased.  The  urine  is 
febrile. 

The  sputum  is  mucoid  or  muco-purulent,  glairy  and  viscid,  and 
may  be  somewhat  rusty  or  blood-streaked.  It  is  difficult  to  raise 
and  almost  never  typically  rusty,  ceasing  with  failing  strength. 


214  THE  BRONCHI  AND  LUNGS 

Subacute  and  chronic  forms  are  known,  presenting  the  same 
general  and  physical  symptoms  but  marked  by  longer  duration  and 
greater  exhaustion. 

Treatment.  The  patient  is  confined  to  bed  in  a  well-ventilated 
room  of  even  temperature,  65°  to  68°  F.,  the  air  being  moistened 
by  steam.  The  position  should  be  changed  frequently  in  the  aged 
and  in  the  very  weak. 

"Feed  milk,  eggs,  broths,  ice  cream  and  gruels  freely ;  also 
give  plenty  of  water  to  drink,  and  keep  the  organs  of  elimination 
wide  open.  Look  carefully  for  upper  dorsal  lesions  above  the 
eighth,  also  the  corresponding  rib  lesions,  which  are  so  often  found 
in  conjunction.  Protect  the  chest  by  a  cotton  batting  jacket,  but 
I  prefer  to  omit  the  antiphlogistine.  Ice  bags  over  the  chest  give 
comfort.  In  cases  with  high  fever,  sponge  the  patient  or  apply  the 
wet  pack.  Keep  close  watch  on  the  heart  for  signs  of  failure,  and 
give  general  relaxation  to  assist  the  circulation  and  raise  the  left 
ribs  to  relieve  the  heart." — W.  H.  Bedwell. 

Reduction  of  the  temperature  is  best  secured  by  deep,  steady 
pressure  in  the  suboccipital  fossa,  or  in  the  mid-thoracic  region. 
During  convalescence,  the  child  must  be  carefully  guarded  to  pre- 
vent relapse,  and  be  built  up  by  tonic  treatment. 

Prognosis.  In  the  primary  cases,  it  is  good,  recovery  following 
prompt  and  thorough  treatment. 

In  feeble  and  debilitated  children  and  in  the  aged,  it  is  unfavor- 
able, although  recovery  may  occur  in  apparently  very  serious  cases. 
In  weakly  subjects,  it  may  terminate  fatally  after  a  protracted 
course  or  develop  into  tuberculosis.  The  aspiration  and  deglutition 
forms  are  usually  fatal. 


CHAPTER  XXII 
DISEASES  OF  THE  LUNGS 

CONGESTION  OF  THE  LUNGS 

Active  congestion  is  an  early  stage  in  many  pulmonary  affec- 
tions, although  this  may  include  some  of  the  abortive  forms  seen 
during  epidemics  of  the  infective  lung  diseases.  It  is  marked  by 
initial  chill,  pain  in  the  chest,  dyspnea,  moderate  cough,  tempera- 
ture 101°  to  103°  F. ;  the  physical  signs  bein'g  defective  resonance, 
feeble  sometimes  bronchial  breathing,  and  fine  rales.  Simple  con- 
gestion clears  while  the  more  serious  diseases  increase  in  severity. 

Passive  congestion  occurs  from  three  classes  of  causes :  Mechan- 
ical congestion  is  found  whenever  there  is  any  obstacle  to  the 
return  of  the  blood  from  the  lungs  to  the  heart  or,  more  rarely, 
from  the  pressure  of  tumors ;  and  is  marked  by  dyspnea,  cough, 
frothy,  often  blood-stained,  sputum  containing  "heart  disease  cells." 
Passive  congestion  occasionally  results  from  injury  or  organic  brain 
.disease.  Hypostatic  congestion  is  found  in  long-continued  fevers 
and  adynamic  states,  the  bases  of  the  lungs  being  deeply  congested 
partly  as  a  result  of  gravity,  but  chiefly  by. the  weak  heart  action, 
the  general  symptoms  being  absent.  The  physical  signs  of  passive 
congestion  are  slight  bilateral  dullness,  feeble,  sometimes  blowing, 
breath  sounds,  the  bases  posteriorly  being  particularly  affected, 
moist  rales,  and  sometimes  increased  vocal  fremitus. 

Treatment.  This  is  the  same  as  the  treatment  of  the  first  stage 
of  pneumonia  (q.  v.).. 


PULMONARY  HEMORRHAGE 

(Hemoptysis;  broncho-pulmonary  hemorrhage;  bronchorrhagia) 

Hemoptysis  is  the  expectoration  of  blood,  pure  or  mixed  with 
air,  usually  bright  red  in  color,  following  the  act  of  coughing. 

Etiology.  Pulmonary  hemorrhage  may  be  caused  by  tubercu- 
losis and  other  pulmonary  diseases;  excessive  cardiac  action,  par- 
ticularly in  the  presence  of  mitral  lesions,  when  it  may  be  profuse 
and  recur  at  intervals  for  years ;  aneurysm  rupturing  into  the  bron- 
chial area;  cancer  or  ulceration  of  the  larynx,  trachea,  or  bronchi; 
gangrene  or  infarction  of  the  lungs ;  traumatism  or  excessive  bodily 
exertion ;  in  hemophilia,  purpura,  and  scurvy ;  rarely  as  an  attempt 
at  vicarious  menstruation ;  recurring  hemoptysis  in  arthritis  sub- 
jects; endemic  hemoptysis  (see  under  animal  parasites). 

215 


216  THE  LUNGS 

Diagnosis.  The  hemorrhage  occurs  suddenly,  is  rarely  preceded 
by  epistaxis,  cardiac  palpitation,  or  some  difficulty  in  breathing; 
begins  with  a  warm  sensation  under  the  sternum,  tickling  in  throat, 
sweetish  taste  in  the  mouth  and  coughing  to  remove  these  sensa- 
tions. It  is  followed  by  a  warm,  saltish,  bright  red,  frothy,  alkaline 
liquid,  gushing  from  the  mouth  and  nose,  composed  of  blood  mixed 
with  air  and  mucus. 

The  appearance  of  the  blood  depresses  the  patient ;  he  becomes 
pale,  and  often  faints.  The  attack  may  subside  within  a  half  hour 
or  several  hours,  returning  for  several  days,  the  sputum  being  either 
bloody  or  blood-streaked.  There  may  be  a  slight  febrile  reaction 
and  chest  pains  afterward  as  a  result  of  inflammation  at  the  site 
of  bleeding. 

Auscultation  reveals  coarse,  bubbling  rales  in  circumscribed 
areas.  It  is  usually  better  not  to  examine  the  chest  until  the  hemor- 
rhage is  stopped. 

Diagnosis  must  be  made  from  epistaxis  by  absence  of  air  bub- 
bles and  by  inspection  of  fauces  and  nasal  cavities;  from  hemat- 
emesis,  by  the  blood  being  vomited  instead  of  expectorated,  and 
being  dark-colored,  clotted,  mixed  with  acid  stomach  contents,  and 
followed  by  black  tarry  stools,  with  absence  of  rales  in  the  chest. 
The  exceptions  are  when  the  blood  from  the  lung  is  swallowed  and 
then  vomited ;  and  when  a  large  gastric  artery  is  eroded  by  ulcer, 
but  the  raising  of  such  "blood  is  preceded  by  epigastric  pain  and  the 
blood  is  rarely  frothy. 

Treatment.  The  patient  should  be  put  to  bed  in  the  dorsal 
semi-recumbent  position,  or  lying  flat  upon  the  affected  side  (de- 
noted by  the  bubbling  rales).  The  blood  can  be  diverted  from  the 
lungs  by  giving  steady  pressure  at  the  sides  of  the  eighth  to  the 
twelfth  thoracic  spinous  processes ;  by  applying  ice  bags  to  the 
affected  side ;  by  applying  heat  to  the  extremities  and  the  abdomen ; 
or,  less  effectively,  usually,  by  bandaging  the  arms  and  legs  to 
delay  venous  return.  Certain  drugs,  as  morphine,  may  quiet  the 
patient  and  diminish  bleeding,  but  the  danger  of  these  is  great; 
the  throat  reflexes  are  lost,  the  patient  may  drown  in  his  own 
blood,  or  he  may  succumb  to  atelectasis  or  pneumonia.  No  food 
or  liquid  should  be  given  for  about  six  hours  after  the  hemorrhage 
stops,  and  should  then  be  only  small  amounts  of  very  cold  liquids, 
or  ice  cream.  Prevention  of  later  attacks  depends  upon  finding  and 
removing  the  cause  of  the  hemorrhage. 


PULMONARY  APOPLEXY 

(Hemorrhagic  infarct;   diffuse   hemorrhagic   infiltration) 

This  is  an  uncommon  form  where  the  blood  is  effused  into  the  alveoli  and 
interstitial  tissues.    It  occurs  in  chronic  heart  disease,  particularly  mitral  lesions, 


EDEMA  217 

in  thrombus  or  embolus  of  the  pulmonary  artery  in  septicemia,  pyemia,  malig- 
nant fevers,  and  in  certain  brain  diseases.  The  symptoms  are  indefinite,  usually 
those  of  pulmonary  embolism  and  thrombosis.  If  the  injury  is  very  large  and 
in  the  lower  lobe,  there  are  signs  of  consolidation  with  blowing,  breathing  and 
pleuritic  friction. 

Treatment.  Perfect  rest  in  bed  with  the  head  and  shoulders  elevated, 
with  absolute  quiet  insisted  upon,  the  patient  being  turned  upon  the  affected 
side,  if  it  is  known,  is  essential.  The  first  thing  to  do  is  to  reassure  the  patient. 
Then  deep  steady  pressure  from  the  second  to  the  fifth  dorsal  vertebrae  de- 
creases the  cardiac  action.  Pressure  near  the  ninth  and  tenth  lowers  blood 
pressure,  the  blood  is  drawn  into  the  abdominal  veins.  No  corrective  work 
should  be  attempted  until  the  bleeding  is  controlled.  As  soon  as  possible  after 
the  hemorrhage,  correction  of  the  subluxations  found,  usually  at  the  third  dor- 
sal, sometimes  from  second  to  the  seventh  dorsal  vertebrae,  clavicles,  upper 
ribs,  or  in  the  cervical  region,  will  assist  in  preventing  a  recurrence.  The  diet 
must  be  bland  and  non-irritating,  with  cool  drinks,  and  ice  to  dissolve  in  the 
mouth.  The  success  of  treatment  depends  upon  the  primary  disease,  and 
measures  must  be  used  to  combat  it. 


PULMONARY  EDEMA 

(Dropsy  of  the  lungs) 

Pulmonary  edema  is  an  accumulation  of  serous  fluid  in  the  air 
vesicles,  bronchioles,  and  interstitial  tissues  of  the  lungs,  asso- 
ciated with  conditions  favoring  hypostatic  congestion,  and  clini- 
cally marked  by  dyspnea,  cough,  and  expectoration  of  frothy,  blood- 
streaked  sputum. 

Etiology.  It  is  associated  with  morbid  blood  states  as  Bright's 
disease,  anemias,  alcoholic  excesses,  and  with  conditions  favoring 
hypostatic  congestion,  as  cardiac  valve  lesions,  malignant  fevers, 
paralysis,  and  long-continued  lying  on  the  back.  It  may  occur 
after  the  use  of  pilocarpin.  The  condition  may  also  follow  aspira- 
tion of  the  thorax.    Upper  thoracic  and  rib  lesions  predispose. 

Diagnosis.  The  onset  is  usually  sudden  with  dyspnea  or 
orthopnea;  the  breathing  is  hurried,  laboring  and  rattling;  all  the 
accessory  muscles  are  used.  Pain  in  the  chest,  sense  of  oppression 
and  anxiety  are  extreme.  The  cough  is  short,  constant,  and  harass- 
ing, followed  by  expectoration  of  copious,  foamy,  serous,  blood- 
streaked  sputum.  The  cardiac  action  is  tremulous  or  feeble.  The 
face  is  flushed  at  first,  but  as  the  left  ventricle  fails,  or  if  the  effusion 
into  the  alveoli  prevents  the  entrance  of  sufficient  air,  symptoms  of 
cyanosis  rapidly  follow,  as  shown  by  the  feeble  pulse,  cold  surface, 
shallow  hurried  breathing,  suppressed  cough,  restlessness  replaced 
by  stupor,  which  soon  deepens  into  coma. 

Percussion  is  not  resonant  at  first,  soon  becoming  dull  at  the 
bases  posteriorly.  The  breath  sounds  are  deficient,  weakened,  with 
subcrepitant  and  bubbling  rales  of  an  unusually  liquid  character. 
The  second  pulmonic  cardiac  sound  is  accentuated.  Hypertension 
usually  precedes  the  edema. 


218  THB  LUNGS 

The  treatment  is  that  of  the  cause,  by  removing  the  obstruction 
to  the  circulation  ancf  securing  free  elimination.  Relaxation  is  indi- 
cated ;  raise  the  ribs  and  clavicles  to  relieve  the  dyspnea.  Inhala- 
tions of  oxygen  may  be  necessary  in  severe  cases. 

Prognosis.  Pulmonary  edema  may  prove  fatal  within  a  short 
time,  or  be  relieved  to  recur  later.  It  is  especially  grave  when  com- 
plicating pneumonia,  and  in  cardiac  or  renal  diseases.  In  the 
majority  of  cases  it  is  a  terminal  affection. 


COLLAPSE  OF  THE  LUNG 

Collapse  of  the  lung  is  a  part  of  other  diseases,  but  is  associated 
with  definite  physical  signs,  and  is  of  several  types. 

Congenital  collapse,  or  atelectasis,  occurs  in  weakly  new-born 
in  whom  the  inspiratory  power  is  not  sufficient  to  properly  inflate 
the  lungs. 

Cases  due  to  pressure  from  without,  as  in  pleural  or  pericardial 
effusion  or  pneumothorax,  may  present  collapse  of  the  whole  lung. 

Cases  are  sometimes  due  to  wounds  of  the  chest  wall  and  per- 
foration of  the  pleura. 

Ordinary  or  lobular  collapse  often  occurs  in  those  cases  ot 
bronchopneumonia  which  complicate  or  follow  measles,  whooping 
cough,  or  other  conditions. 

Collapse  may  be  due  to  paralysis  of  the  respiratory  muscles, 
the  elastic  recoil  of  the  lung  tissues  being  aided  by  absorption  of 
air  by  the  blood  vessels. 

Diagnosis.  If  an  extensive  area  is  involved,  any  existing 
dyspnea  becomes  increased,  the  pulse  more  rapid,  and  cyanosis  may 
follow.  'In  slight  cases,  the  symptoms  of  the  primary  disease  only 
are  present — the  "grippy  chest"  of  milder  cases  of  bronchopneu- 
monia. If  the  area  is  extensive,  dullness  and  possibly  tubular 
breathing  are  present. 

Auscultation  discloses  subcrepitant  rales  and  weakened  respira- 
tory murmur. 

Treatment.  The  primary  disease  must  receive  first  attention. 
The  patient  must  be  taught  full  breathing,  holding  the  lungs  full 
of  air  for  progressively  lengthening  periods.  If  the  heart  is  good, 
cold  shower  baths,  or  having  cold  water  poured  upon  the  back  of 
the  neck,  stimulates  the  respiratory  organs.  Care  must  be  used, 
lest  the  shock  to  the  heart  be  serious. 

Prognosis.  When  the  condition  is  due  to  pressure,  as  in  em- 
physema, the  outlook  is  very  grave.  When  the  area  involved  is 
not  great,  and  no  active  infectious  agent  is  present,  symptomatic 
recovery  may  be  expected. 


EMPHYSEMA  219 

EMPHYSEMA 

(Alveolar  ectasis) 

This  term  is  applied  to  several  rather  widely  different  ,condi- 
tions,  all  of  which  are  characterized  by  the  presence  of  abnormally 
large  air  spaces  in  the  lungs.  Two  classes  are  recognized — inter- 
lobular and  vesicular. 

Interlobular  or  Interstitial  Emphysema  is  the  presence  of  air 
spaces  outside  the  lung  cavity,  in  the  interstitial  tissues,  or  rarely 
entirely  outside  the  organ.  It  is  due  to  rupture  of  the  alveolar  walls 
during  violent  expiratory  effort.  The  causes  include :  violent  cough- 
ing, as  in  whooping-cough  or  bronchitis;  urgent  straining,  as  in 
parturition,  defecation,  muscular  effort,  or  hysterical  fits ;  and 
injuries  to  the  lung,  as  stab  or  gunshot  wounds,  etc.  The  air 
usually  escapes  upon  the  anterior  aspect  of  an  upper  lobe;  if  it 
escapes  from  other  areas,  it  is  apt  to  work  upward  through  the 
mediastinum,  until  it  reaches  the  neck  region,  when  its  further 
progress  is  impeded.  One  of  my  cases  (Burns)  had  a  sac  as  large 
as  a  walnut,  upon  the  upper  aspect'  of  the  left  superior  lobe.  Un- 
less bacteria  are  carried  in  with  the  air,  no  harm  results.  No  treat- 
ment is  required. 

Vesicular  Emphysema  is  due  to  dilatation  of  the  alveoli.  Sev- 
eral types  of  this  are  recognized,  each  with  certain  peculiarities. 

Compensatory  or  Inspiratory  Emphysema  is  a  condition  in 
which  a  portion  of  the  lung  expands  to  take  the  place  of  a  collapsed 
portion,  as  in  bronchopneumonia,  pleuritic  adhesions,  or  in  an  area 
of  old  tubercular  cicatrice. 

Atrophic  or  small-lunged  emphysema  is  due  to  primary  senile 
atrophy  of  the  lungs,  the  chest  and  lungs  being  small. 

Hypertrophic,  substantive,  or  expiratory  emphysema,  which  is 
the  usual  form,  is  due  to  those  causes  which  keep  up  a  more  or  less 
persistent  high  intra-alveolar  tension,  such  as  playing  on  wind 
instruments  and  glass-blowing;  occupations  involving  severe  strain 
or  heavy  lifting ;  chronic  bronchitis ;  heredity,  probably  depending 
upon  congenital  weakness  of  the  elastic  tissues  of  the  lung.  Any 
of  these  causes  produces  overdistension  of  the  vesicles ;  atrophy 
of  their  walls;  obliteration  of  the  blood  vessels  and  a  consequent 
diminution  of  the  oxygenating  area;  changes  in  the  chest  contour; 
changes  in  the  right  heart;  general  changes  due  to  imperfect 
oxygenation ;  and  often  an  associated  bronchiectasis.  The  condi- 
tion is  clinically  marked  by  the  physical  signs,  dyspnea,  and  a 
chronic  bronchitis. 

Diagnosis.  The  general  symptoms  are  not  many  until  the  con- 
dition is  well  advanced  and  consist  of  dyspnea  and  cyanosis  from 
the  deficient  aeration.    These  are  greatly  increased  on  exertion,  and 


220  THE  LUNGS 

the  patient  is  able  to  go  about  with  cyanosis  of  an  extreme  grade ; 
more  or  less  cough  from  associated  bronchitis;  retention  of  waste 
products  within  the  blood  causing  various  disagreeable  symptoms ; 
the  temperature  is  subnormal ;  the  surface  of  the  body,  cool ;  and 
the  pulse  is  weak.  Hypertrophy  and  dilatation  of  the  right  heart 
with  its  symptoms  of  general  venous  stasis  follow. 

The  chest  is  large,  barrel-shaped,  with  round  shoulders;  the 
dorsal  curve  of  the  spine  is  increased  and  rounded ;  the  scapulae 
are  almost  horizontal,  there  are  prominent  sternum,  clavicles,  and 
stemo-mastoid  muscles,  a  deep  sternal  fossa;  the  intercostal  spaces 
are  widened,  the  vertical  diameter  is  elongated.  The  neck  veins  are 
distended.  The  auxiliary  muscles  are  used.  Prolonged  expiration 
with  a  short  inspiration  is  noted.  A  zone  of  dilated  venules  may 
be  found  along  the  line  of  attachment  of  the  diaphragm. 

Vocal  fremitus  is  diminished,  the  cardiac  impulse  is  depressed 
and  nearer  the  sternum,  the  apex  being  only  rarely  palpable.  Epi- 
gastric pulsation  may  be  present. 

There  is  a  drum-like  note  to  the  hyper-resonance  which  extends 
to  the  seventh  and  eighth  rib'  anteriorly  and  to  the  twelfth  pos- 
teriorly, if  the  whole  lung  is  involved.  The  areas  of  cardiac  and 
hepatic  fullness  are  encroached  upon ;  the  margins  of  the  lung  are 
fixed  in  the  position  of  full  inspiration  from  the  disappearance  of 
elastic  tissue.  The  vesicular  murmur  is  soft  and  weak,  even  absent, 
depending  upon  the  amount  of  bronchitis  present.  The  breath 
sounds  are  wheezy  and  harsh  on  expiration.  The  first  cardiac  sound 
is  lessened  in  intensity  and  duration;  the  second  sharply  ac- 
centuated. 

Treatment.  The  bronchitis  often  associated  with  emphysema 
must  receive  attention.  Whatever  other  causative  factors  are  found 
must  be  removed,  if  this  is  possible.  During  expiration,  an  attend- 
ant should  exert  pressure  upon  the  thorax,  relaxing  as  inspiration 
occurs.  Inspiration  against  pressure  upon  the  ribs  gives  exercise 
to  the  inspiratory  muscles,  though  this  is  of  less  importance.  A 
nurse  can  be  taught  to  give  this  manipulation,  and  the  exercises 
should  be  selected  after  due  study  of  the  patient's  condition,  and 
especially  the  positions  of  the  ribs.  It  is  best  to  see  that  rib  lesions 
have  been  well  corrected  before  any  strenuous  measures  are  ad- 
vised. Cardiac  lesions  are  to  be  suspected,  and  no  violent  exertion 
permitted  until  the  suspicion  has  been  allayed. 

Breathing  in  compressed  air,  and  breathing  out  into  negative 
pressure,  tends  to  remove  the  superfluous  air,  and  to  give  exercise 
to  the  muscles  of  respiration.  Raising  the  ribs  and  clavicles  often 
gives  relief. 

The  general  health  must  be  maintained  in  every  way.  The 
hygiene,  exercise,  diet,  are  those  of  the  underlying  cause,  plus  the 
measures    indicated    in    chronic    bronchitis.      Sudden    attacks    of 


ABSCESS  221 

dyspnea  may  occur,  and  these,  though  rarely  fatal,  are  serious.    In 
such  cases  oxygen  may  be  required  for  relief. 

The  prognosis  is  clouded.  Patients  seldom  die  from  the  condi- 
tion. When  the  emphysema  is  associated  with  asthmatic  attacks, 
the  prognosis  is  more  serious.  Cardiac  changes  are  frequent,  and 
death  may  be  due  to  injury  to  the  right  heart.  General  edema  may 
terminate  the  condition. 


PULMONARY  GANGRENE 

Infection  of  the  diseased  tissue  by  any  of  the  proteolytic  organ- 
isms may  result  in  gangrene  of  the  lungs.  It  may  follow  abscess 
or  pneumonia,  especially  in  very  old  people,  or  those  in  whom  the 
bodily  resistance  is  greatly  lowered  for  any  reason.  The  most 
important  distinctive  diagnostic  symptoms  are  the  odor  of  the 
breath  and  the  general  symptoms  of  toxemia.  Treatment  of  this 
disease  is  of  very  little  use.  Death  usually  supervenes  within  a 
very  few  days. 

ABSCESS  OF  THE  LUNGS 

Pulmonary  abscess  results  from  the  infection  of  the  lungs  by 
any  of  the  pyogenic  organisms.  Staphylococcus  or  streptococcus 
are  the  most  frequently  found.  These  may  infect  tissue  already  dis- 
eased by  pneumonia  or  tuberculosis. 

"Cold  Abscess"  may  be  due  to  infection  by  the  tubercle  bacilli, 
or  by  actinomyces.  Abscess  of  the  liver  may  penetrate  the  dia- 
phragm and  drain  through  the  lungs.  In  this  case,  the  presence 
of  bile  in  the  sputum  gives  the  diagnosis. 

Treatment.  Drainage  through  the  bronchi  may  be  sufficient, 
and  recovery  occur  spontaneously.  If  drainage  is  not  complete, 
the  treatment  is  the  surgical  evacuation  of  the  pus.  Resection  of 
one  or  more  ribs  may  be  necessary. 

In  any  case  the  treatment  should,  include  a  careful  examina- 
tion of  the  condition  of  the  liver  and  the  kidneys.  The  circulation 
through  these  organs  and  the  spleen  should  be  kept  very  free,  in 
order  that  the  normal  bactericidal  conditions  of  the  body  may  not 
be  interfered  with. 

The  prognosis  is  grave  in  any  case. 

PNEUMOKONIOSIS 

This  term  is  applied  to  the  condition  of  the  lungs  almost  uni- 
versally present  in  the  cities,  or  even  in  country  places,  where  soft 
coal  is  burned.  The  inhalation  of  particles  of  soot  is  inevitable. 
These  are  taken  up  by  the  white  blood  corpuscles,  or  are  passed 


222  THB  LUNGS 

through  the  alveolar  epithelium  into  the  lymph  channels.  The 
connective  tissues  are  colored  dark  gray  or.  black,  and  the  bronchial 
lymph  nodes  are  very  deeply  colored.  The  alveolar  cells  them- 
selves may  be  permeated  with  the  black  particles. 

When  this  discoloration  is  due  to  particles  of  coal,  as  in  miners, 
the  term  "anthracosis"  is  used. 

Those  who  work  in  stone  and  breathe  the  fine  particles  of  this 
dust  suffer  from  "chalicosis." 

Those  who  work  in  iron  and  breathe  the  fine  particles  of  this 
dust  suffer  from  "siderosis." 

In  all  of  these  cases,  the  resisting  capacity  of  the  lungs  is  dimin- 
ished appreciably.  The  injury  to  the  epithelium  lowers  the  resist- 
ance to  infections,  and  thus,  pneumokoniosis  must  be  considered 
one  of  the  causes  of  pneumonia,  tuberculosis  and  other  less  com- 
mon disorders. 

RARE  PULMONARY  CONDITIONS 

Hydatid  Cysts  may  be  found  in  the  lungs. 

It  is  possible  to  diagnose  this  condition  only  when  the  booklets 
are  found  in  the  sputum  which,  in  such  cases,  is  usually  thin  and 
watery.    Lung  stones  are  rarely  found. 

Bronchial  Calculus.  C.  C.  Wright  reports  a  case  of  bronchial 
calculus  with  recovery.  The  calculus  was  "a  hard,  jagged  stone 
of  a  dirty  white  color,  nodular  coral-like  surface,  and  under  strong 
glass  looked  like  bone.  Its  dimensions  were  12  by  9  by  6  m.m., 
and  weight  10  grains.  No  blood  followed  it  and  no  soreness  pre- 
ceded or  followed  its  expulsion." 

Primary  Carcinoma  is  very  rare  in  the  lungs.  It  is  usually  found 
in  the  upper  lobe  of  the  right  lung,  and  it  may  attain  great  size. 
Secondary  carcinoma  is  usually  from  mammary  carcinoma,  though 
it  may  follow  similar  growths  anywhere  else  in  the  body.  These 
secondary  tumors  are  usually  small  and  very  numerous. 

Sarcoma  is  usually  secondary,  and  its  most  frequent  origin  is 
in  the  pulmonary  lymphatic  glands. 

Diagnosis.  Pulmonary  ■  neoplasms  are  rarely  suspected  ante 
mortem.  The  X-ray  may  give  the  diagnosis.  The  only  treatment 
is  symptomatic,  and  the  prognosis  is  extremely  grave.  Death 
usually  occurs  within  a  few  months  after  the  first  symptoms  are 
noticed. 

PLEURISY 

(Pleuritis) 

Etiology.  Inflammation  of  the  pleura  is  usually  the  result  of 
inflammation  of  the  lungs.  It  is  almost  invariably  present  in  pneu- 
monia, tuberculosis,  bronchitis,  or  in  almost  any  other  pulmonary 


PLEURISY  721 

inflammation.  The  few  primary  cases  are  due  either  to  trauma 
or  to  severe  exposure  to  cold  and  wet.  Repeated  attacks  indicate 
pulmonary  tuberculosis. 

Systemic  diseases,  such  as  rheumatism,  nephritis,  alcoholism, 
may  cause  pleurisy  with  little  or  no  lung  involvement.  The  right 
pleura  may  be  inflamed  in  cases  of  hepatitis.  Three  forms  of 
pleurisy  are  described :  the  acute,  subacute,  and  chronic. 

Acute  fibrinous  pleurisy,  dry  pleurisy,  or  acute  plastic  pleurisy 
is  the  most  common  condition.  The  disease  begins  with  a  sense 
of  discomfort,  followed  by  dyspnea  and  pain  in  one  side  of  the 
trunk,  "stitch  in  the  side."  There  is  a  little  cough,  which  is  sup- 
pressed on  account  of  the  pain  which  it  produces.  A  slight  fever 
may  be  present.  The  symptoms  may  be  very  mild  and  the  attack 
last  only  a  few  days.  At  other  times,  the  symptoms  are  much  more 
severe  and  acute,  and  may  last  for  several  weeks,  or  may  terminate 
fatally. 

Treatment.  The  most  important  part  of  the  treatment  is  the 
relief  of  the  pain.  Painful  areas  may  be  strapped  with  bands  of 
adhesive  tape.  Rib  lesions  should  be  corrected  at  the  beginning 
of  the  disease,  if  this  is  possible.  It  is  frequently  impossible  to 
correct  the  rib  lesions  after  the  inflammation  has  become  pro- 
nounced. Hot  and  cold  applications  may  relieve  the  pain.  Coun- 
ter-irritation may  be  indicated.  Rest  in  bed  is  always  necessary 
during  the  acute  symptoms. 

Prognosis.  Most  cases  recover  in  a  few  days  unless  there  is 
some  marked  pulmonary  disease.  Every  attack  predisposes  to  fur- 
ther attacks.  When  the  inflammatory  process  does  not  disappear, 
the  condition  may  pass  into  the  subacute  or  the  chronic  form. 

Subacute  pleurisy,  pleurisy  with  effusion,  sero-fibrinous  pleu- 
risy, may  follow  the  acute  attack,  but  it  usually  begins  with  a 
much  slower  sequence  of  symptoms.  After  a  day  or  two  of  pain, 
slight  cough,  dyspnea,  the  normal  secretions  begin  to  be  con- 
siderably increased.  The  fluid  may  accumulate  to  such  an  extent 
as  to  exert  compression  upon  the  lungs  or  the  heart.  Dyspnea  is 
progressively  more  marked.  The  cardiac  disturbances  may  be 
very  severe. 

The  diagnosis  rests  upon  the  area  of  dullness  which  may  change 
with  the  changing  position  of  the  patient.  The  normal  heart  and 
breath  sounds  are  mufiled  by  the  fluid  over  them. 

Diaphragmatic  pleurisy  is  associated  with  nausea,  vomiting, 
pain  in  the  pit  of  the  stomach,  and  other  symptoms  of  gastro- 
intestinal disturbances.    The  X-ray  may  be  helpful  in  diagnosis. 

Encysted  effusion  is  due  to  the  adhesion  of  the  inflamed  pleural 
membranes  around  an  accumulation  of  fluid  which  may  increase 
in  quantity  through  a  considerable  extent. 


224  THE  LUNGS 

Interlobar  pleurisy  occupies  the  region  between  the  lobes  of  the 
lungs  and  may  drain  into  a  bronchus.  Hemorrhagic  pleurisy  is 
due  to  the  extravasation  of  blood  into  the  pleural  exudate. 

About  three-fourths  of  the  cases  of  subacute  pleurisy  are  tuber- 
cular in  origin,  though  the  tubercle  bacilli  are  rarely  found  in  the 
fluid.  The  condition  may  be  a  part  of  the  symptoms  of  acute  artic- 
ular rheumatism. 

A  fever  of  usually  not  more  than  103°  F.  may  be  present.  The 
whole  course  of  the  disease  is  slow  and  convalescence  is  usually 
greatly  retarded.  Tubercular  cases  often  recover  from  the  pleurisy, 
though  the  pulmonary  disease  may  follow  its  usual  course. 

One  of  the  most  important  factors  in  the  cause  of  pleurisy  is 
the  existence  of  rib  lesions.  The  inflamed  area  may  be  covered  by 
the  ribs  or  may  be  on  a  side  of  the  thorax  opposite  the  ribs,  whose 
adjustment  is  imperfect.  It  must  not  be  forgotten,  however,  that 
the  reflex  muscular  contractions  due  to  the  inflamed  pleura  cause 
the  approximation  of  the  ribs  and  the  disturbance  of  their  structural 
relations. 

Chronic  adhesive  pleurisy  may  follow  any  of  the  other  types  of 
pleurisy  mentioned.  It  may  or  may  not  be  associated  with  consid- 
erable effusion.  Sometimes  both  forms  are  found  present  at  the 
same  time;  that  is,  the  two  layers  of  the  pleura  may  be  adherent 
with  connective  tissue  bands  of  varying  strengths,  while  the  areas 
not  adherent  are  engaged  in  pouring  out  an  abundant  fluid.  This 
form  is  especially  frequent  in  chronic  rheumatism  and  in  nephritis. 
The  pain  is  well  localized  and  is  increased  by  movements  of  the 
thorax,  or  the  arms,  by  deep  respiration,  or  by  coughing.  The 
effusion  may  embarrass  the  respiration  and  the  heart's  action  to  a 
considerable  extent. 

Paracentesis  is  necessary  when  the  accumulation  of  fluid  be- 
comes great  enough  to  interfere  with  the  respiration  and  the  cir- 
culation to  any  great  extent.  It  may  have  to  be  repeated  rnany 
times.  Occasionally  a  single  draining  is  followed  by  adhesion  of 
the  pleural  membrane. 

This  form  does  not  usually  shorten  life,  but  it  predisposes  to 
other  diseases,  and  may  make  life  a  very  uncomfortable  matter. 


EMPYEMA 

(Purulent  pleuritis  or  pleurisy;  pleuritic  abscess) 

The  infection  of  a  pleuritic  exudate  may  result  in  empyema. 
The  infectious  agent  may  gain  entrance  into  the  bronchial  cavity 
by  careless  paracentesis,  or  it  may  be  carried  from  an  infectious 
area  elsewhere  in  the  body  by  means  of  the  blood  stream.  Direct 
extension  from  pulmonary  abscesses  or  from  the  liver  or  any  other 
abdominal  abscess  through  the  diaphragm  is  rare.    An  examination 


THE  MEDIASTINUM  225 

of  the  pus  may  show  any  of  the  pyogenic  organisms  singly  or  in 
combination. 

Diagnosis.  The  dull  area  is  usually  rather  less  in  extent  than 
is  the  case  in  pleurisy  with  effusion.  The  pain  may  or  may  not 
be  very  severe.  The  constitutional  symptoms  are  much  more 
marked  than  in  other  forms  of  pleurisy.  The  fever  may  reach  107° 
F.  The  blood  shows  marked  leucocytosis.  Peptonuria  and  indican- 
uria  are  usually  present.  Gastro-intestinal  symptoms  are  those 
ordinarily  associated  with  the  fever. 

Pulsating  empyema  (pulsating  pleurisy,  empyema  necessitas), 
is  due  to  the  presence  of  considerable  amounts  of  pus,  walled  off. 
and  circumscribed  by  adhesions  of  the  two  pleural  layers  around  it. 

Treatment.  The  pus  should  be  evacuated  and  the  wall  of  the 
cavity  thoroughly  cleaned  as  soon  as  a  diagnosis  is  made.  Resec- 
tion of  one  or  more  ribs  is  often  necessary  in  order  to  provide  suf- 
ficient drainage. 

With  early  drainage,  rest  in  bed  and  the  treatment  of  such 
symptoms  as  may  complicate  the  case,  recovery  should  be  expected. 
In  old  p^»ople,  or  in  those  in  whom  the  vitality  is  greatly  lowered 
for  any  feason,  the  prognosis  is  very  serious. 

Sequelae.  The  danger  of  metastatic  abscesses  must  be  kept  in 
mind.  The  pus  or  bacteria  may  be  carried  in  the  blood  to  the  liver, 
the  brain,  kidneys,  or  any  other  organ  in  the  body.  With  septi- 
cemia, the  prognosis  is  most  serious, 

PNEUMOTHORAX 

Puncture  of  the  thoracic  wall,  or  as  the  result  of  an  injury  to 
considerable  of  the  alveoli,  may  permit  air  to  enter  the  intrathoracic 
cavity  after  pulmonary  abscess.  This  condition  is  called  pneumo- 
thorax. Rarely,  aerogenic  organisms  may  infect  the  pleural  cavity. 
The  treatment  is  surgical. 

HYDROTHORAX 

(Dropsy  of  the  pleura;  thoracic  dropsy) 

The  accumulation  of  non-inflammatory  fluid  in  the  pleural  cavity 
is  due  to  the  same  condition  which  causes  dropsy  elsewhere  in  the 
body ;  that  is,  nephritis,  cirrhosis  of  the  liver,  valvular  lesions  of 
the  heart,  etc.  The  treatment  is  that  of  the  underlying  disease. 
Paracentesis  may  be  necessary. 

DISEASES  OF  THE  MEDIASTINUM 

The  diseases  of  the  mediastinum  are  not  very  frequently  found. 
Lymphadenitis  may  be  present.    Abscess  in  the  mediastinum  is  due 


226  THE  LUNGS 

to  about  the  same  causes  as  before  mentioned  for  empyema.  Either 
abscess  or  tumors  may  extend  into  the  mediastinum  from  the 
esophagus,  bronchi  or  lungs.  Hemorrhage  of  the  mediastinum  is 
due  to  rupture  of  a  thoracic  aneurysm. 

The  symptoms  produced  by  these  tumors  are  mostly  due  to 
pressure.  In  metastatic  growths  the  diagnosis  rests  upon  finding 
the  original  tumor.  In  certain  lymphomatous  tumors,  excising  a 
small  gland  from  the  neck  for  microscopical  examination  may  give 
useful  information. 

Compression  of  the  aorta  may  give  murmurs  like  those  of 
aortic  stenosis.  Unequal  pulse  in  the  two  radials  is  apt  to  follow 
compression  of  the  left  subclavian  or  the  innominate  artery. 
When  the  esophagus  is  aflFected,  dysphagia  and  pain  result.  The 
bougie  or  X-ray  examination,  especially  with  thick  barium  paste, 
should  show  the  cause  of  the  symptoms.  Pressure  upon  the 
phrenic  may  give  obstinate  attacks  of  hiccough.  Pressure  upon 
other  nerves  gives  varying  pain,  weakness,  pupillary  disturbances, 
gastric  symptoms,  hyperidrosis  and  other  symptoms  referable  to 
the  function  of  the  affected  nerves. 

The  position  and  shape  of  the  mediastinum  varies  normally 
during  respiration,  and  abnormally  as  the  result  of  pathological 
changes  in  its  neighboring  organs.  Pleural  or  pericardial  effusions, 
pneumothorax,  and  other  variations  in  the  size  or  the  shape  of  the 
lungs  or  the  heart,  may  cause  marked  variations  in  the  size  and 
form  of  the  mediastinum.  Inflammatory  changes  may  result  in 
cicatricial  thickening  and  this  may  lessen  the  normal  elasticity  of 
the  mediastinal  walls;  the  contraction  of  this  new  tissue  may  pull 
the  mediastinum  into  a  distinctly  lateral  position. 

Neoplasms  of  the  mediastinum  include  those  from  lymph  nodes, 
as  in  Hodgkin's  disease  or  lymphadenosis;  sarcoma,  which  may  be 
primary  or  secondary ;  carcinoma,  which  is  probably  always  sec- 
ondary, or  the  peculiar  thymus-sarcoma  or  thymus-carcinoma. 
Dermoids  may  be  found  in  the  mediastinum.  Supernumerary 
thyroid  masses  may  be  found ;  these  cause  no  symptoms  unless 
they  undergo  hypertrophy  or  hyperplasia,  as  in  goiter.  Echinococ- 
cus  cysts,  tubercles,  gummy  masses,  are  not  often  found. 

In  all  these  cases,  diagnosis  is  difficult  or  impossible  and  treat- 
ment extremely  doubtful.  The  X-ray  may  be  of  value  in  diagnosis. 
The  prognosis  is  always  very  serious. 


PART  IV 
DISEASES  OF  THE  BLOOD 


GENERAL  DISCUSSION 

The  blood  is  one  of  the  most  complicated  of  the  tissues  of  the 
body.  It  differs  from  ordinary  tissue  in  that  its  cells  are  not  formed 
within  it,  unless  we  should  include  the  red  bone  marrow  and  the. 
lymphoid  tissues  of  the  body  as  part  of  the  blood  system.  The 
intercellular  substance  of  blood  serum  is  not  derived  from  the  activ- 
ity of  the  blood  cells,  but  is  composed  of  the  material  poured  into 
the  blood  through  the  lymphatic  duct,  absorbed  from  the  digestive 
tract,  picked  up  all  over  the  body  with  a  load  of  the  products  of 
cellular  metabolism,  and  it  contains  dissolved  within  it  the  internal 
secretions,  waste  products  and  many  highly  complex  substances 
which  are  being  carried  for  the  use  of  other  cells  of  the  body,  or 
which  are  on  the  way  to. elimination. 

The  red  blood  cells  of  adult  life  are  formed  within  the  red  bone 
marrow,  and  this  is  found  plentifully  within  the  ribs.  The  granular 
white  blood  cells  are  formed  within  the  red  bone  marrow  also ;  the 
hyalin  blood  cells  are  formed  chiefly  in  the  lymph  nodes  of  the  body 
and  partly  within  the  red  bone  marrow. 

When  this  complex  nature  of  the  blood  and  the  many  sources 
of  its  various  constituents  are  recognized,  it  is  easily  seen  that  the 
nature  of  the  blood  diseases  and  the  causes  of  primary  and  sec- 
ondary anemias  must  be  extremely  variable. 

From  the  standpoint  of  the  physician,  the  chief  interest  in  the 
blood  diseases  lies  in  the  fact  that  all  the  erythrocytes  and  all  the 
granular  cells  are  formed  in  the  red  bone  marrow.  This  is  found 
in  the  flat  bones  of  the  body;  the  skull,  scapulas,  innominates  and 
ribs  are  the  most  important  areas  of  blood  formation.  Of  these 
areas,  the  largest  amount  is  found  in  the  ribs.  It  must  be  remem- 
bered that  the  ribs  receive  nutrient  arteries,  veins  and  nerves  by 
way  of  the  foramina  upon  their  lower  edges.  Man  stands  upright, 
and  the  weight  of  the  thorax  exercises  a  constant,  though  slight, 
pressure  upon  these  vessels  and  nerves.  The  nerves  are  both 
spinal  and  sympathetic,  as  are  the  nerves  of  other  vessels  and 
active  tissues.  The  spinal  segments  are  subject  to  the  effects  of 
bony  lesions,  and  thus  these,  as  well  as  the  effects  of  direct  pressure, 
may  be  involved  in  the  control  of  the  blood-forming  cells  and  the 
vessels  which  supply  them. 

In  order  to  make  good  blood  cells,  the  marrow  must  receive  the 
materials  from  the  blood  brought  to  it.    The  necessary  food  ele- 

227 


228  GENERAL  DISCUSSION 

merits  must  be  taken  into  the  body,  properly  digested,  and  absorbed 
and  carried  by  the  blood  to  the  marrow ;  it  is  evident  that  anything 
which  prevents  the  normal  eating  and  digestion  of  food,  the  normal 
circulation  of  the  blood,  and  the  normal  nervous  control  of  the 
vessels  and  the  intrinsic  cells  of  the  marrow,  must  inevitably  affect 
the  quality  or  the  quantity  of  the  blood  cells  being  manufactured. 

Infectious  agents  may  be  carried  by  the  blood  from  one  part 
of  the  body  to  another,  as  in  arthritis;  parasites  may  have  the 
blood  as  their  habitat,  as  in  malaria;  tumor  cells,  fragments  of 
vegetations,  and  other  foreign  bodies  may  be  carried  in  the  current 
of  the  blood  stream  to  various  parts  of  the  circulatory  system,  with 
serious  or  trivial  effects  upon  physiological  integrity.  Thus  is  the 
blood  an  important  factor  in  pathogenesis. 

As  the  blood  circulates  through  the  body,  it  takes  up  various 
substances,  the  products  of  normal  or  abnormal  metabolism.  These 
exert  various  influences  upon  the  blood  cells  in  circulation,  and  also 
upon  the  hematopoietic  cells  in  the  bone  marrow.  These  changes 
can  be  recognized  from  the  study  of  the  blood,  and  thus  the  blood 
is  an  important  factor  in  diagnosis. 

The  blood  serum  contains  within  it  organic  and  inorganic  com- 
pounds of  great  complexity,  including  ferments  whose  number  and 
function  have  been  little  studied.  Some  of  these  appear  to  be 
bacteriolytic,  either  directly  or  indirectly,  while  others  digest  for- 
eign substances  which  gain  entrance  into  the  blood,  or  which  result 
from  thrombosis  or  other  pathological  states  of  the  blood  itself. 
The  body  is  thus  protected  against  disease,  though  this  protection 
is  not  always  adequate.  The  blood  itself  is  an  important  factor  in 
preventing  disease  and  in  promoting  recovery. 

The  treatment  of  the  blood  diseases  must  be  based  upon  these 
facts ;  and  the  only  thing  that  can  be  done  is  to  provide  the  marrow 
with  good  blood  making  materials,  carried  freely  to  the  marrow 
and  to  provide  that  the  drainage  of  the  wastes  from  the  marrow 
and  from  the  blood  itself  shall  be  normal,  and  to  remove  anything 
which  interferes  with  the  normal  nervous  control  of  the  tissues 
concerned  in  the  feeding,  manufacture,  or  cleansing  of  the  blood. 


CHAPTER  XXIII 
THE  ANEMIAS 

SECONDARY  ANEMIA 

The  term  anemia,  which  literally  means  "without  blood,"  is  now 
applied  to  a  condition  of  the  body  in  which  the  blood  is  low  in 
hemoglobin.  The  blood  may  be  low  in  hemoglobin,  either  because, 
it  contains  fewer  than  the  required  number  of  red  blood  cells,  each 
of  which  is  itself  reasonably  normal,  or  it  -may  be  due  to  the  fact 
that  the  individual  cells  carry  too  small  an  amount  of  hemoglobin, 
though  the  number  may  be  almost  or  quite  normal. 

As  the  name  implies,  secondary  anemia  is  due  to  the  effect  pro- 
duced upon  the  blood  by  some  disease  of  other  organs  of  the  body. 
These  diseases  afifect  the  blood  in  varying  ways,  so  that  in  a  large 
majority  of  cases  it  is  possible  for  an  examination  of  the  blood  to 
determine  the  condition  of  many  of  the  organs  of  the  body  and  the 
source  of  origin  of  the  disease.  It  is  usually  easy  after  a  blood 
examination  has  been  made  to  say  whether  there  is  present  some 
primary  disease  of  the  blood,  or  the  blood  forming  organs,  or 
whether  the  entire  blood  picture  is  simply  the  result  of  a  disturbed 
metabolism,  or  the  disturbed  function  of  diseased  organs  elsewhere 
in  the  body. 

Anemia  which  is  the  result  of  sudden  hemorrhage  or  of  certain 
forms  of  malnutrition,  has  its  hemoglobin  diminished  as  the  result 
of  the  loss  of  the  red  blood  corpuscles.  Anemia  which  is  the  result 
of  slower  chronic  diseases,  usually  associated  with  disturbed  cir- 
culation through  the  red  bone  marrow  of  the  body,  has  usually  a 
slightly  diminished  red  cell  count,  but  a  large  majority  of  the  red 
blood  cells  contain  less  than  the  normal  amount  of  hemoglobin. 
The  amount  of  hemoglobin  in  each  cell  may,  in  some  cases,  be  as 
low  as  one-fourth  that  present  in  a  normal  adult  blood  cell. 

In  secondary  anemias  a  study  of  the  white  blood  cells  is  of 
considerable  importance.  Pernicious  anemia,  as  well  as  secondary 
anemia  due  to  the  action  of  non-inflammatory  etiological  factors, 
is  characterized  by  a  white  blood  cell  count  almost  or  quite  normal, 
and  in  which  the  varying  classes  of  white  blood  cells  are  about 
those  found  in  normal  adult  human  blood.  In  tuberculosis  the 
white  blood  count  shows  an  increase  in  the  lymphocytes  and  de- 
crease in  eosinophiles.  In  the  ordinary  neuroses  and  in  hysteria, 
the  eosinophiles  are  increased  and  the  polymorphonuclear  cells  are 
usually  diminished.  In  nearly  all  secondary  anemias  due  to  the 
presence  of  intestinal  parasites  from  the  hookworm  to  the  tape- 

229 


230  THB  ANEMIAS^ 

worm,  the  number  of  eosinophiles  is  very  conspicuously  increased. 
In  secondary  anemia  due  to  purulent  inflammations  anywhere  in 
the  body,  the  number  of  neutrophiles  is  greatly  increased.  In  all 
of  these  conditions  the  changes  in  the  blood  are  of  the  degenerative 
type. 

There  is  another  form  of  anemia  usually  classed  as  secondary, 
in  which  the  blood  deficiency  is  of  congenital  origin.  This  is  called 
a  developmental  type.  While  the  underlying, blood  defect  is  con- 
genital, these  defects  are  often  increased  as  the  result  of  patholog- 
ical conditions  occurring  at  any  time  during  the  life  of  the  indi- 
vidual. Congenital  blood  defects  are  recognized  by  the  presence 
in  the  blood  stream  of  immature  or  atavistic  cell  types.  These 
include  neucleated  red  cells,  oval  red  cells,  and  poikilocytes.  The 
white  cell  count  shows  an  increase  in  the  relative  number  of 
lymphocytes,  amphophiles,  myelocytes  and  mononuclear  neutro- 
philes. When  these  cells  are  found  in  blood  which  is  being  exam- 
ined for  diagnostic  purposes,  the  prognosis  for  complete  recovery 
is  made  somewhat  more  grave,  and  in  mental  defectives  complete 
recovery  is  scarcely  to  be  expected. 

Secondary  anemias  due  to  the  presence  of  poisons  may  be 
pathognomonic.  The  basophilic  stippling  of  the  red  blood  cells  in 
lead  poisoning  is  characteristic.  Toxins  due  to  proteid  decomposi- 
tion, to  the  presence  of  bile  in  the  blood,  and  to  disturbance  of  the 
metabolism  in  constitutional  diseases,  injure  blood  cells  more  or 
less  seriously.  Naked  nuclei,  fractured  cells,  bloated  forms, 
shadows,  and  poikilocytes  are  indicative  of  the  presence  of  some 
toxin  in  the  blood  serum. 


COSTOGENIC  ANEMIA 

(Burns  anemia) 

Costogenic  anemia  is  a  disease  of  the  blood  due  to  imperfect 
blood  formation,  resulting  from  deficient  circulation  and  innerva- 
tion of  the  red  bone  marrow,  especially  of  the  ribs,  and  character- 
ized clinically  by  marked  weakness,  pallor,  hemic  murmurs  of  the 
heart,  and  other  symptoms  of  anemia ;  by  the  low  color  index  and 
the  presence  of  immature  and  atavistic  cells  in  the  blood  stream. 

Etiology.  The  disease  is  due  to  disturbed  activity  of  the  hemat- 
opoietic organs,  resulting  from  disturbed  circulation  through  the 
red  bone  marrow,  or  from  disturbed  innervation  of  the  vessels  or 
of  the  active  blood-forming  elements. 

Lesions  affecting  the  circulation  through  the  scapulae,  innomi- 
nates,  and  skull  are  less  important  than  lesions  affecting  the  circu- 
lation of  the  comparatively  much  greater  area  of  the  red  marrow  in 
the  ribs.  The  mobility  of  the  thorax  may  be  lessened,  and  undue 
pressure  thus  be  brought  upon  the  nerve  trunks,  the  veins  and  the 


COSTOGENIC  ANEMIA  231 

arteries  which  enter  the  nutrient  foramina  of  the  ribs,  by  several 
different  and  various  conditions.  Perhaps  one  of  the  most  frequent 
is  the  drooping  of  the  thorax,  which  occurs  in  people  whose  mus- 
cles are  atonic — who  are  weak  from  any  cause,  or  whose  daily  lives 
do  not  include  a  sufficient  amount  of  exercise.  Partly  because  of 
faulty  education  in  the  line  of  self-control — which  is  wrongly  inter- 
preted as  self-repression — partly  because  of  improper  clothing,  and 
partly  because  of  the  stress  of  modern  living,  the  ribs  are  allowed 
to  droop  more  and  more.  Thus  the  circulation  through  the  rib 
marrow  is  impeded,  and  thus  the  nerve  centers  in  the  spinal  cord 
fail  to  receive  their  due  and  proper  amount  of  stimulation  from  the 
joint  surfaces  and  muscles. 

Diagnosis.  The  onset  is  gradual,  unless  it  follows  some  other 
disease.  Weakness,  insomnia  or  drowsiness,  gas  accumulations  in 
stomach  and  intestines :  tense,  anxious  expression ;  pale  sallow  skin 
— sometimes  vascular  dilatation  may  give  rosy  cheeks — slow  diges- 
tion ;  and  usually  constipation,  are  present.  The  symptoms  are  not 
pathognomonic.  The  thorax  is  found  rather  rigid,  with  extremely 
small  chest  expansion  in  quiet  breathing;  rarely  forced  breathing 
gives  a  fairly  satisfactory  expansion.  The  intercostal  muscles  are 
usually  hard,  and  show  the  intercostal  depressions  plainly.  The 
urine  shows  lack  of  elimination;  the  quantity  may  be  normal  or 
slightly  increased  in  twenty-four  hours,  with  low  sp.  gr.,  sometimes 
1002 ;  low  urea,  low  phosphates,  low  sulphates,  less  frequently  low 
chlorides ;  no  albumin,  casts,  or  indications  of  organic  disease.  Ex- 
cess of  indican  may  be  present ;  calcium  oxalate  is  frequent. 

The  blood  itself  is  rather  characteristic.  Coagulation  time  is 
increased ;  specific  gravity  and  viscidity  diminished ;  red  cell  count 
normal  or  only  slightly  diminished ;  hemoglobin  6  to  10  grams  per 
100  c.c.  of  blood  (Meischer)  ;  40%  to  80%  (Dare).  The  red  cells 
are  small,  pale,  vacuolated,  sometimes  nucleated.  The  white  cell 
count  is  normal,  slightly  increased  or  slightly  diminished.  The 
hyaline  cells  are  normal,  or  slightly  relatively  increased.  (These, 
being  formed  in  lymph  nodes,  tonsils,  etc.,  are  not  affected  by  rib 
changes.)  The  mononuclear  neutrophiles  are  relatively  increased. 
The  nuclear  average  of  the  polymorphonuclear  neutrophiles  is  low. 
Vacuolated  and  atypical  neutrophiles  are  often  found.  Basophiles, 
myelocytes  and  amphophiles  may  be  found  in  considerable  num- 
bers. Nuclei  in  all  granular  forms  present  evidences  of  immaturity 
or  degeneration — they  may  be  swollen,  vacuolated,  extruded, 
ragged,  or  with  variable  staining  reactions. 

Treatment.  The  treatment  is  indicated  by  the  etiology  and 
diagnosis.  Most  important  is  the  raising  of  the  ribs,  ^nd  the  teach- 
ing of  proper  respiratory  activities.  Whatever  is  wrong  with  the 
patient's  habits  of  living  must  be  corrected.  A  diet  which  includes 
an  abundance  of  green  vegetables,  meat,  and  fruits,  with  only  a 


232  ,  THE  ANEMIAS 

moderate  amount  of  starch  and  sugar,  is  best  adapted  to  blood 
making-. 

Prognosis.  With  efficient  treatment  and  obedience,  recovery- 
should  be  thorough  and  permanent.  If  the  case  is  neglected,  or  if 
the  bad  habits  are  too  hard  to  be  overcome,  the  patient  is  apt  to 
live  a  subnormal  individual,  or  a  chronic  invalid  until  some  inter- 
current affection  terminates  his  days. 

Prophylaxis.  This  is  easy.  It  is  only  to  use  the  ribs  freely ;  to 
compel  free  breathing,  especially  under  emotional  tension  of  any 
kind,  and  to  refrain  from  any  habits  of  dress,  breathing  or  living 
that  lessen  the  respiratory  excursions  of  the  ribs. 


CHLOROSIS 

Chlorosis,  "green  sickness,"  is  a  disease  of  adolescent  girls, 
characterized  by  anemia  of  an  edematous  type,  circulatory  disturb- 
ances of  a  nervous  type,  and  a  varying  number  of  neurotic  symp- 
toms. The  name  "green  sickness"  refers  to  the  peculiar  yellow- 
green  color  of  the  skin. 

The  etiology  is  not  known.  Various  theories  refer  to  the  pres- 
ence of  characteristics  which  may  or  may  not  be  themselves  due  to 
some  preexisting  etiological  factor.  The  disease  being  found  in 
its  typical  form  only  in  young  girls,  especially  those  who  suffer 
from  menstrual  difficulties,  compels  the  view  that  disturbed  secre- 
tion of  the  ovaries  is  an  important  etiological  factor.  A  some- 
what similar  condition  has  been  reported  in  adolescent  boys. 

That  the  disease  is  associated  with  the  first  wearing  of  corsets 
gives  another  theory  of  the  cause  of  the  disease.  Constipation, 
often  of  a  very  severe  type,  is  almost  always  present.  For  this 
reason  copremia  may  be  considered  of  etiological  importance. 

The  heart  is  often  of  small  size,  and  functional  cardiac  murmurs 
are  often  present.  Aplasia  of  the  blood  vessels  is  frequent.  This 
gives  color  to  the  view  that  a  developmental  defect,  becoming  evi- 
dent only  when  the  onset  of  the  puberty  changes  necessitates  con- 
siderable increased  strain  upon  these  organs,  is  the  true  cause  of 
the  disease.  Gastric  ulcer  and  exophthalmic  goiter  are  frequent 
complications. 

Tuberculosis  and  other  diseases  associated  with  poor  nutrition 
either  in  the  individual  or  in  her  ancestors  increases  the  tendency 
to  chlorosis.  A  direct  inheritance  of  chlorosis  is  not  rare — in  the 
Pacific  College  Clinic  a  chlorotic  woman  was  examined,  whose 
mother,  grandmother  and  great-grandmother  had  all  suffered  from 
chlorosis. 

Chlorotic  girls  have  always  deficient  mobility  and  usually  local- 
ized lesions  involving  the  mid-thoracic  region.    The  most  frequent 


CHLOROSIS  233 

lesion  is  a  slightly  posterior  and  decidedly  rigid  condition  affecting 
the  third  or  fourth  to  the  tenth  or  twelfth  thoracic  vertebrae,  and 
the  related  ribs.  The  chest  expansion  in  both  quiet  and  forced 
respiration  is  diminished;  rarely,  after  a  girl  has  taken  breathing 
exercises  or  calisthenics  the  forced  expansion  may  be  increased. 
But  in  all  except  rapidly  improving  patients  the  respiratory  excur- 
sion is  diminished  habitually.  The  fact  that  diminished  oxygena- 
tion is  habitual  is  shown  by  certain  symptoms  of  the  disease,  and 
also  by  the  constant  sighing  usually  noticed. 

Diagnosis.  The  disease  is  of  gradual  onset.  The  girl  becomes 
weaker  and  paler,  and  gives  evidences  of  cardiac  difficulty.  Sigh- 
ing, emotionalism,  dyspnea,  palpitation,  headache,  abnormal  appe- 
tites— clay-eating,  pencil  and  hair-chewing — a  greenish  tint  around 
the  eyes  and  mouth,  lack  of  interest  in  work  or  play,  usually  with- 
out emaciation,  sometimes  with  increase  in  weight,  are  character- 
istic. The  diagnosis  rests  absolutely  upon  the  blood  examination. 
The  typical  "chlorotic  cell"  is  a  large  erythrocyte,  swollen,  pale,  and 
spherical.  It  is  present  in  other  diseases,  but  not  so  frequently 
nor  so  typically  as  in  chlorosis.  The  total  amount  of  blood  is 
increased. 

An  average  of  eleven  typical  cases  of  chlorosis  examined  at  the 
Pacific  College  of  Osteopathy  gives  the  following  results : 

Hemoglobin,  40%  (Dare). 

Erj'throcytes,  3,780,000  per  cubic  millimeter;  84%. 

Color  index,  .45. 

Poikilocytes  always  present. 

Chlorotic  cells  always  present.  * 

Microcytes  usually  present. 

Normoblasts  usually  present. 

Leucocytes,  8,500  per  cubic  millimeter,  many  atavistic  forms 
present. 

Lymphocytes,  37%,  or  3,145  per  cubic  millimeter. 

Neutrophiles,  58.8%,  or  4,978  per  cubic  millimeter;  many  frac- 
tured. 

Eosinophiles,  1.3%,  or  110  per  cubic  millimeter. 

Basophiles,  .3%,  or  26  per  cubic  millimeter. 

Amphophiles,  few. 

Arneth's  index  was  shifted  slightly  to  the  left:  Neutrophile 
nuclear  average,  diminished. 

Coagulation,  time  increased. 

Viscidity,  diminished. 

Platelets  usually  diminished. 

Treatment.  The  treatment  rests  upon  the  facts  as  already  dis- 
cussed. The  correction  of  the  rigidity  of  the  thorax,  the  drooping 
ribs,  the  spinal  lesions,  is  an  essential  factor  in  restoring  health. 
The  circulation  through  the  abdomen  must  be  kept  competent. 


234  THE  ANEMIAS 

The  ribs  over  the  liver  and  spleen  must  be  raised,  and  deep  breath- 
ing exercises  compelled.  The  respiratory  expansion  in  quiet  and 
forced  respiration  must  be  measured  with  a  tape,  and  the  findings 
recorded.  At  intervals  of  a  few  days  to  several  weeks,  the  meas- 
urements must  be  repeated,  and  progress  noted.  If  no  progress  is 
found,  the  girl  is  failing  in  her  obedience  to  the  instructions  given 
her. 

The  pelvic  condition  must  receive  whatever  attention  is  indi- 
cated by  the  gynecological  examination.  In  neurotic  girls,  espe- 
cially, this  must  be  postponed,  unless  immediately  urgent,  and  must 
be  made  under  all  precautions  to  avoid  nervous  shock.  Correction 
of  innominate  or  sacral  lesions  may  correct  the  pelvic  disturbance 
with  no  further  treatment  of  any  kind.  The  love  affairs  must  be 
investigated;  pseudo-romantic  imaginations,  the  reading  of  love 
stories  and  too  great  indulgence  in  moving  pictures  or  theatrical 
performances,  especially  with  strong  love  interest,  are  to  be  inter- 
dicted. Good,  clean,  wholesome  discussion  of  the  problems  of  life, 
duty,  death,  birth,  marriage,  religion,  poetry  and  romance  helps  to 
overcome  any  effects  of  emotional  repressions  which  may  be  active 
in  perpetuating  ovarian  congestion  and  respiratory  inefficiency. 

The  constipation  is  best  met  by  enemas  to  secure  immediate 
cleaning  of  the  colon,  followed  by  the  correction  of  the  thoracic, 
lumbar  and  costal  lesions.  The  better  diet,  the  breathing  exercises, 
with  the  correction  of  the  lesions  as  noted,  should  be  sufficient. 
Enemas  may  be  used,  if  anything  further  is  necessary.  Purgative 
drugs  are  urgently  to  be  avoided.  The  abnormal  appetites  are  best 
gfatified  in  a  modified  way — lemons  or  grape  fruit  may  be  substi- 
tuted for  vinegar;  a  largely  cellulose  diet  usually  prevents  an  appe- 
tite for  hair,  while  honey,  candy,  and  other  sweets  with  meals  make 
it  easier  to  stop"  the  candy-munching  habit  between  meals.  The 
necessary  iron  is  best  given  in  the  form  of  chlorophyll  or  hemo- 
globin. The  juices  of  vegetables  and  meats  may  be  given,  if  the 
foods  themselves  are  not  tolerated. 

If  the  weakness  is  profound,  the  patient  should  lie  quietly  for 
half  an  hour  after  meals ;  if  she  is  given  to  day-dreaming,  her  wak- 
ing hours  must  be  filled  with  useful  employment,  preferably  some- 
thing in  which  she  can  be  interested,  and  which  requires  her  entire 
attention.  Change  of  scene  may  be  wonderfully  effective,  especially 
if  the  usual  love  affair  looms  big  in  etiology. 

Prognosis.  Recovery  is  usually  gradual  and  uneventful  and  com- 
plete. If  the  girl  who  has  had  chlorosis  becomes  subject  to  hemor- 
rhages, accident,  or  other  cause  of  secondary  anemia  later  in  life, 
her  blood  is  apt  to  show  some  chlorotic characteristics.  But,  unless 
there  is  some  very  efficient  cause  of  anemia,  she  is  apt  to  live  her 
life  out  without  any  ill  effects  from  her  chlorotic  experience. 


HEMOLYTIC  ANEMIA  235 


HEMOLYTIC  ANEMIA 

(Primary  anemia;   idiopathic  anemia;   pernicious   anemia;  Biermier's  disease; 

Addison's  anemia) 

This  is  a  disease  of  the  blood  characterized  by  rapid  and  progres- 
sive destruction  of  the  blood  cells,  with  rapid  but  insufficient  re- 
generation, progressive  weakness  to  death,  and  for  which  no  cause 
has  been  determined. 

Etiology.  The  cause  of  the  disease  in  its  typical  form  is  un- 
known. The  state  of  the  blood  cells  ante-mortem,  and  the  patho- 
logical findings  at  autopsy  indicate  the  presence  of  some  intense 
hemolytic  poison,  which  acts  not  only  upon  the  red  blood  cells, 
but  also  upon  the  nervous  system,  and  to  a  less  marked  extent 
upon  the  other  tissues  of  the  body.  Anemia,  not  to  be  distin- 
guished from  the  idiopathic  type,  is  sometimes  due  to  the 
bothriocephalus  latus,  the  ankylostome  duodenalis,  the  necator 
americanus,  and  perhaps  certain  other  intestinal  parasites.  The 
frequent  presence  of  dry  tongue,  sore  mouth,  deficient  hydrochloric 
acid  in  the  gastric  juice,  and  intermittent  diarrhea  and  constipation, 
suggest  a  gastro-intestinal  origin  for  the  destructive  toxins.  Gastro- 
intestinal malignant  neoplasms  also  may  give  symptoms  and  a 
blood  picture  greatly  resembling  that  of  idiopathic  anemia;  exhaust- 
ing diseases,  chlorosis,  pregnancies,  syphilis,  malaria,  in  their  more 
severe  forms,  may  be  followed  by  anemias  of  the  pernicious  type, 
though  less  certainly  fatal.  In  some  cases  successive  pregnancies 
may  be  associated  with  a  milder  anemia  of  this  type;  the  intervals 
between  pregnancies  being  characterized  by  almost  or  quite  normal 
blood  counts.  Before  the  age  thirty-five,  more  women  have  the 
disease ;  after  thirty-five,  more  men. 

Pathology.  The  autopsy  findings  are  typical.  The  yellow  or  green- 
ish skin  is  characteristic;  the  fat  is  of  a  brilliant  orange  color.  The  muscles 
have  an  unusually  deep  and  brilliant  scarlet ;  while  the  blood  remains  for  days 
uncoagulated,  and  flows  like  pink-stained  water.  The  red  bone  marrow  fills  the 
long  bones,  and  penetrates  them,  as  well  as  the  flat  bones,  almost  or  quite  to 
the  periosteum.  Irregular  and  variable  areas  of  degeneration  are  found  in  the 
spinal  cord  and  the  brain.  These  correspond  to  the  nervous  symptoms  present 
before  death.     Atrophy  of  the  gastro-intestinal  glands  is  almost  constant. 

Diagnosis,  Only  after  exhausting  every  possible  cause  of  sec- 
ondary anemia  is  the  diagnosis  of  pernicious  anemia  possible,  since 
so  many  of  the  cases  above  mentioned  present  fairly  typical  blood 
pictures.  The  symptoms  are  fairly  typical,  but  not  absolutely  so; 
the  onset  is  very  insidious ;  the  disease  is  rarely  suspected  until  the 
weakness  and  pallor  have  become  profound.  The  deficient  hydro- 
chloric acid  is  sometimes  recognized  early,  in  the  search  for  a 
cause  for  the  gastro-intestinal  symptoms.  This  deficiency  persists 
through  the  course  of  the  disease.  At  first  there  are  dyspnea, 
weakness,  palpitation  of  the  heart,  pallor,  easy  fatigue,  and  perhaps 


236  THE  ANEMIAS 

some  gastro-intestinal  or  nervous  symptoms.  This  is  followed  by 
progressing  weakness  and  cardiac  symptoms,  increasing  diarrhea, 
nausea  and  vomiting,  perhaps  some  submucous  or  subcutaneous 
hemorrhages.  Pain  is  infrequent  and  never  severe,  unless  there  is 
some  intercurrent  affection.  Paresthesias,  ataxias,  paralyses,  amau- 
rosis, may  suggest  some  structural  disease  of  the  nervous  system 
— the  patient  may  first  seek  advice  concerning  the  nervous  system. 
The  skin  changes  from  waxy  white  or  yellowish  to  a  peculiar 
lemon  yellow  color,  sometimes  a  greenish  yellow  is  present;  the 
conjunctivae  and  mucous  membranes  are  of  the  same  tint.  Emacia- 
tion is  not  marked ;  the  apparent  amount  of  fat  may  increase.- 
Mental  changes  do  not  appear  until  the  weakness  is  almost  deadly-^ 
then  there  is  somnolence. 

Cardiac  murmurs  are  often  found;  the  pulse  may  be  weak  and 
rapid,  or  it  may  be  full,  "water  hammer,"  like  that  of  aortic  regur- 
gitation ;  though  this  lesion  is  rarely  present.  The  urine  shows  the 
pigment  in  excess,  excess  of  indican,  sometimes  excess  of  uric  acid 
and  urea.    Albumin  and  blood  are  not  usually  present. 

With  progressive  weakness  and  dyspnea,  the  patient  finally  be- 
comes bedfast,  and  dies  after  more  or  less  stupor  and  mild  delirium. 
The  termination  may  appear  sudden;  the  patient  may  be  walking, 
even  upon  the  streets,  until  a  very  few  days  before  dissolution. 

Blood.  The  blood  changes  are  remarkable.  The  hemoglobin 
is  reduced  to  a  very  low  figure  (1.5  grams  per  100  c.c.  in  one  P.  C. 
O.  patient).  Hemoglobin  percentages  of  20,  (Dare)  and  even  lower 
are  frequently  reported. 

The  red  cell  count  is  even  lower  than  the  hemoglobin  percent- 
age; the  color  index  is  thus  above  one,  which  is  normal.  A  color 
index  of  1.3  or  1.5  or  even  higher  is  not  unusual.  This  factor  is  of 
value  in  diagnosis;  while  a  high  color  index  may  be  found  in  sec- 
ondary anemia  due  to  parasites,  etc.,  yet  in  these  the  color  index 
is  almost  never  so  high,  so  constantly,  as  in  idiopathic  anemia. 
The  red  cells  include  abundant  poikilocytes,  megalocytes,  micro- 
cytes,  normoblasts,  and  microblasts.  Vacuoles,  ring-like  bodies, 
stippling,  and  other  degenerated  forms  appear.  The  megalocytes 
are  pathognomonic;  the  high  color  index  is  due  to  their  abundance. 
Oval  nucleated  cells,  like  those  of  nonmammalia,  are  sometimes 
found.  The  finding  of  considerable  numbers  of  megaloblasts 
shortly  precedes  death.  Rarely  these  cells  may  be  found  in  small 
numbers,  and  the  patient  live  for  some  weeks  or  months;  but  if 
even  a  few  are  present  the  prognosis  is  very  grave. 

The  white  cells  are  not  greatly  changed,  especially  in  the  early 
stages.  In  most  secondary  anemias,  the  white  cells  share  the  dis- 
turbance;  this  is  not  so  in  idiopathic  anemia;  the  number  of  the 
white  cells,  and  their  relations  are  not  much  diflferent  from  the 
normal.    Toward  the  close  of  life  these  assume  manv  atavistic  and 


HEMOLYTIC  ANEMIA  '  237 

degenerated  forms,  but  leucocytosis  is  not  present,  nor  is  there 
marked  eosinophilia ;  this  latter  fact  differentiates  intestinal  para- 
sites fairly  accurately.  Myelocytes  appear ;  these  probably  origi- 
nate from  the  erythrogenic  rather  than  the  leukogenic  areas.  The 
platelets  are  reduced;  viscidity,  specific  gravity,  coagulability  are 
all  low. 

Treatment.  No  adequate  treatment  of  idiopathic  anemia  is 
known.  The  secondary  forms  require  treatment  indicated  for  the 
causative  disease.  In  doubtful  cases  treatment  for  intestinal  para- 
sites may  be  given,  and  the  feces  closely  watched.  The  anemia 
should  promptly  improve  upon  removal  of  the  worms. 

For  the  idiopathic  cases,  an  urgent  endeavor  should  be  made  to 
find  out  the  source  and  nature  of  the  hemolytic  poison.  Failing 
this,  symptomatic  treatment  should  be  initiated ;  certainly  this  gives 
the  patient  his  best  chance  of  securing  intermissions,  and  of  living 
more  comfortably;  perhaps  longer.  The  intestinal  and  renal  and 
pulmonary  activity  should  be  maintained  by  the  use  of  plenty  of 
fresh  air  and  fresh  water.  Free  and  plentiful  water  drinking  should 
promote  elimination  to  the  greatest  possible  extent.  The  gastro- 
intestinal symptoms  are  best  met  by  free  drinking  of  water  and 
fruit  juices,  milk  and  broths,  and,  if  necessary  by  nutrient  enemas. 
Friction  baths  promote  skin  activity ;  hot  and  cold  bathing  is  to 
be  advised  with  care.  The  patient  is  to  rest  much,  especially  in  the 
recumbent  position,  in  the  open  air  as  much  as  can  possibly  be 
managed.  A  warm  climate  is  best.  Give  plenty  of  nourishing 
food.  The  green  vegetables  are  best ;  if  they  cannot  be  eaten  raw, 
give  the  juice  pressed  from  the  raw,  ground  vegetables.  It  should 
be  freshly  made  daily,  should  be  greatly  diluted  in  hot  or  cold 
water,  but  ought  not  to  be  cooked,  or  put  into  boiling  water.  Use 
this  scantily  for  a  few  days;  half  a  teaspoonful  with  each  meal  is 
enough,  at  first.  Increase  after  three  days,  gradually.  Too  hasty 
feeding  of  this  concentrated  juice  may  cause  a  sore  mouth.  Broiled 
beefsteak,  other  appetizing  foods,  eggs,  milk,  anything  that  is  pleas- 
ant, nutritious,  easily  digested,  and  especially  that  which  the  patient 
wishes,  in  reason,  is  to  be  given  him. 

Spinal  and  costal  lesions  vary ;  there  is  usually  some  rigidity  of 
the  thorax;  this  should  be  corrected.  Such  lesions  as  are  present, 
on  the  examination  of  each  patient,  are  to  be  corrected.  Care  must 
be  employed  to  avoid  fracture  of  the  long  bones,  especially  in  the 
correction  of  innominate  lesions ;  the  thinning  of  the  bones,  by 
the  red  marrow,  may  leave  them  extremely  fragile.  At  each  treat- 
ment the  ribs  should  be  freely  raised,  and  held  in  that  position 
through  one  to  three  long  breaths.  The  liver  is  to  be  treated 
directly,  and  the  lower  ribs  raised  from  the  liver  and  spleen.  Man- 
ipulation of  the  abdomen  is  best  avoided,  unless  there  is  some 
urgent  indication  therefor. 


238  THE  ANEMIAS 

Prognosis.  Remissions  may  be  hoped  for;  these  may  last  for 
a  year  or  more.  Unless  there  is  some  remission,  death  may  be 
expected  within  a  year  from  the  time  of  the  diagnosis.  In  many 
cases,  the  disease  progresses  more  rapidly.  If  an  underlying  cause 
is  found,  and  removed,  recovery  may  be  expected  rather  promptly. 
In  such  cases,  the  blood-forming  organs  appear  to  retain  some 
effects  of  their  experience ;  such  a  patient,  having  any  cause  of 
anemia  later,  is  apt  to  show  blood  cells  characteristic  of  idiopathic 
anemia. 

Prophylaxis.  Since  the  nature  and  cause  of  the  disease  are 
unknown,  the  prevention  of  idiopathic  anemia  is  impossible.  The 
severe  secondary  types  are  to  be  avoided  by  early  and  unremitting 
attention  to  the  causes  of  secondary  anemia,  especially  to  intestinal 
parasites. 

INFANTILE  ANEMIA.  (Anemia  infantum  pseudoleukemia;  pseudo- 
leukemia of  children;  von  Jaksch's  anemia.)  This  is  a  rare  disease  of  children 
under  four  years,  characterized  by  greatly  enlarged  spleen,  evidences  of  eryth- 
rocyte destruction,  and  increase  in  the  white  cells. 

The  etiology  is  unknown ;  it  is  usually  associated  with  rickets  or  with 
some  wasting  disease,  gastro-intestinal  disorders,  syphilis,  or  tuberculosis. 
The  increasing  wasting  and  pallor,  with  the  enlarged  spleen,  suggest  the  diag- 
nosis, which  is  proved  by  the  blood  examination.  The  red  cells  diminish  to 
3,000,000  or  less,  while  the  white  cells  may  rise  to  100,000  or  more.  Poikilo- 
cytes,  stippled  red  cells,  vacuolated  and  nucleated  erythrocytes  are  found.  The 
white  cells  retain  their  normal  proportions  for  a  child  of  that  age. 

The  treatment  is  that  of  the  causative  disease,  plus  that  for  other  sec- 
ondary anemias.  The  prognosis  is  as  good  as  that  of  the  primary  disease, 
whose  course  it  seldom  modifies. 

SPLENIC  ANEMIA.  (Banti's  Disease.)  This  is  an  infectious  disease 
of  the  spleen  and  the  blood-forming  organs,  characterized  by  extremely  rapid 
increase  in  the  size  of  the  spleen,  rapidly  developing  anemia,  and  death. 

The  anemia  due  to  long-continued  malarial  invasion,  associated  with  large 
spleen,  is  sometimes  called  splenic  anemia — it  is  not  properly  so  called,  though 
malaria  may  predispose  to  the  true  form  of  Banti's  disease.  The  same  is  true 
of  rachitis  and  syphilis,  which  are  often  given  as  causes  of  the  disease. 

Diagnosis.  The  spleen  is  very  much  enlarged  and  is  painful.  The  red 
bone  marrow  shows  inflammatory  changes.  The  lymph  nodes  may  or  may 
not  be  enlarged.  Weakness  and  emaciation  are  the  first  symptoms,  then  splenic 
and  hepatic  enlargement,  then  hemorrhages,  jaundice,  ascites,  and  death.  The 
blood  shows  the  chlorotic  picture — red  cells,  3.000.000  or  less,  hemoglobin  re- 
duced much  more  greatly,  with  a  color  index  of  one  half  or  even  lower.  Leu- 
copenia  is  usual. 

Treatment.  The  usual  treatment  for  anemia  should  be  given,  plus  raising 
the  ribs,  and  the  correction  of  anything  found  in  the  structure  or  the  occupa- 
tion of  the  patient  that  might  interfere  with  the  circulation  of  the  spleen  or 
the  red  bone  marrow.  Recurring  hematemesis  should  suggest  the  propriety  of 
removal  of  the  spleen. 

GAUCHER'S  DISEASE.  (Large-celled  splenomegaly.)  This  is  a  rare 
here'ditary  disease,  affecting  females  mostly.  It  is  characterized  by  enormous 
splenic  enlargement;  a  brownish  discoloration  of  the  skin;  tendency  to  hemor- 
rhages in  mucous  membranes  and  skin;  thickening  of  skia.  and  conjunctivae; 


RARB  TYPES  239 

and  fairly  good  blood  and  health.  The  blood  examination  distinguishes  it  from 
other  diseases  with  which  it  might  be  confused.  The  spleen  contains  a  remark- 
able number  of  very  large  endothelial  cells,  whose  origin  and  function  are  un- 
known. The  treatment  is  that  of  splenic  anemia.  The  prognosis  is  good  for 
life  and  comfort,  but  recovery  from  the  chronic  state  is  not  to  be  expected. 
Improvement  may  occur.    It  may  develop  into  Banti's  disease  later,  with  death. 

POLYCYTHEMIA.  This  is  a  rare  blood  disease,  most  often  found  in 
middle  aged  Jews,  either  men  or  women.  It  is  clinically  characterized  by  ver- 
tigo, headache,  gastro-intestinal  symptoms,  cyanosis,  and  splenic  enlargement. 
The  blood  count  gives  the  diagnosis — red  cells  may  reach  10,000,000,  but  may  not 
be  so  high ;  hemoglobin  may  reach  20  g.  per  100  c.c.  of  blood — about  150%  of  the 
normal.  The  color  index  is  usually  about  .75,  the  white  cell  count  is  about 
normal,  though  the  mononuclears  may  be  slightly  increased.  The  total  amount 
of  blood  is  increased.  •  Several  slight  variations  in  type  have  been  reported. 
No  satisfactory  treatment  has  been  found;  venesection  gives  temporary  relief; 
splenectomy  is  advised.  The  prognosis  is  bad,  and  death  occurs  with  toxic 
symptoms,  or  from  hemorrhage. 

CHLOROMA.  (Green  tumor.)  Thig  is  a  rare  disease,  characterized  by 
a  sarcomatous  growth  in  the  orbital  bones  and  tissues.  It  contains  a  greenish 
pigment,  whence  the  name.  The  spleen  and  lymphatic  nodes  are  often  enlarged ; 
there  is  a  gangrenous  stomatitis;  pain  in  and  around  the  eye  and  mouth,  deaf- 
ness, and  a  very  severe  anemia.  The  blood  picture  may  be  that  either  of  per- 
nicious anemia,  or  of  acute  lymphatic  or  myelogenous  leukemia.  X-rays  have 
delayed  the  growth  of  some  of  the  tumors,  and  are  without  benefit  to  others. 
No  other  treatment  has  been  found  of  any  use.  The  disease  terminates  in  death 
in  a  few  months,  with  symptoms  of  malignant  cachexia. 

BLASTOMYCOTIC  ANEMIA.  Infection  of  the  blood  by  certain  of 
the  smaller  yeasts  has  been  studied  in  the  laboratories  and  clinics  of  the  Pacific 
College  and  of  the  A.  T.  Still  Research  Institute.  The  infectious  agent  gains 
entrance  through  abrasions  in  the  skin ;  other  modes  of  entrance  may  be 
found  on  further  study.  Predisposing  causes  include  malnutrition  and  excessive 
carbohydrate  diet.  Diminished  alkalinity  of  the  blood  has  been  present  in  the 
cases  studied. 

The  symptoms  vary  according  to  the  organs  most  seriously  involved.  Pul- 
monary invasion  suggests  tuberculosis ;  the  recognition  of  the  yeast  in  the 
blood  and  sputum,  with  the  absence  of  tubercle  bacilli  and  the  more  indolent 
progress  of  the  disease  give  the  correct  diagnosis  of  blastomycosis.  The  pres- 
ence of  yeast  in  the  sputum  alone  is  not  significant.  The  skin  is  often  the  seat 
of  peculiar  dry  scabby  sores.  Invasion  of  the  joints  causes  vague  pains  sug- 
gestive of  rheumatism,  but  not  associated  with  as  marked  inflammatory  changes. 
The  systemic  symptoms  include  sighing,  malaise,  weakness,  evanescent  slight 
chills  and  feverishness,  insomnia  and  drowsiness  and  other  symptoms  suggestive 
of  autointoxication,  but  without  furred  tongue,  foul  breath  or  evidence  of 
gastro-intestinal  disturbance. 

Treatment  consists  in  promoting  nutrition  and  elimination  and  blood 
formation,  as  in  secondary  anemia.  The  organisrn  disappears  from  the  per- 
ipheral blood  under  treatment  and  good  hygienic  conditions,  but  tends  to 
reappear  under  adverse  nutritional  states. 


CHAPTER  XXIV 
THE  LEUKEMIAS 

ACUTE  LYMPHATIC  LEUKEMIA 

Acute  lymphatic  leukemia  is  a  rare  disease,  characterized  by 
sudden  onset  with  high  fever,  rapid  and  pronounced  increase  in 
the  lymphocytes,  the  rapid  development  of  emaciation,  dyspnea 
and  early  death.    Etiology  is  unknown. 

Diagnosis.  The  early  symptoms  are  atypical.  They  are  weak- 
ness, emaciation,  insomnia,  sometimes  edema,  and  other  symptoms 
characteristic  of  cancerous  cachexia.  The  lympathic  glands  all  over 
the  body  and  the  spleen  undergo  marked  and  rapid  increase  in  size. 

The  diagnosis  rests  upon  the  onset  with  high  fever,  the  en- 
larged lymph  nodes,  and  the  result  of  the  blood  examination.  The 
red  cells  are  not  materially  changed  early  in  the  disease;  later 
they  undergo  the  changes  characteristic  of  secondary  anemia  of 
the  toxic  type.  The  most  remarkable  finding  is  the  great  number 
of  lymphocytes.  At  first  these  are  all  small,  but  later  the  large 
lymphocytes  are  greatly  increased  and  considerable  numbers  of 
basophilic  hyalin  myelocytes  are  present.  The  total  white  cell 
count  rarely  exceeds  100,000  perhaps  with  99.5%  of  lymphocytes. 
The  blood  picture  in  the  very  last  stages  of  acute  lymphatic 
leukemia  is  not  to  be  distinguished  from  that  in  acute  spleno- 
medullary  leukemia. 

The  most  marked  change  in  the  urine  is  the  presence  of  consid- 
erably increased  amounts  of  uric  acid  and  other  purin  bodies. 

The  course  of  the  disease  is  rapid  and  death  is  to  be  expected 
within  a  few  months  to  two  years  after  the  first  symptoms  are 
noted.  It  is  improbable  that  any  treatment  can  interfere  with  the 
course  of  this  disease. 

The  symptoms  may  be  relieved  by  treatment  adapted  to  the  con- 
dition of  the  patient  upon  examination.  The  most  important  factor 
in  the  care  of  these  patients  is  to  make  the  diagnosis  accurately 
and  give  whatever  directions  are  necessary  as  to  the  general  care. 

CHRONIC  LYMPHATIC  LEUKEMIA 

(Chronic  lymphadenoid  leukemia;  chronic  lymphadenosis) 

Chronic  lymphatic  leukemia  is  now  known  to  be  somewhat  less 
rare  than  was  earlier  supposed.  It  is  a  disease  of  the  lymph  nodes 
of  the  body,  characterized  by  a  slow  development  of  cachexia. 
The  symptoms  of  chronic   rheumatism — weakness,  dyspnea,  and 

240 


SPLBNOMYELOGENO US  LE UKEMIA  241 

pain — develop  slowly,  and  the  condition  is  likely  to  be  mistaken 
for  rheumatism.  The  excessive  uric  acid  in  the  urine  is  charac- 
teristic, both  of  chronic  lymphatic  leukemia  and  of  gout  or  rheuma- 
tism. Rather  early  in  the  disease  the  lymph  nodes  of  the  body  are 
slightly  enlarged;  the  spleen  is  usually  slightly  enlarged. 

Only  the  blood  examination  can  give  the  diagnosis.  The  red 
cell  count  and  the  hemoglobin  are  usually  about  normal ;  the  actual 
number  of  the  neutrophiles  is  about  normal ;  the  small  lymphocytes 
are  increased,  reaching  about  10,000  per  cu.  mm. ;  the  large  lymph- 
ocytes are  increased  proportionately  with  the  small.  The  disease 
may  at  any  time  show  an  acute  exacerbation,  when  the  symptoms 
characteristic  of  acute  lymphatic  leukemia  occur,  and  this  may 
result  in  the  death  of  the  patient.  The  total  white  cell  count  may 
run  up  to  500,000,  with  60%  or  more  small  lymphocytes. 

The  relation  between  chronic  lymphatic  leukemia  and  acute 
lymphatic  leukemia  appears  to  be  somewhat  as  that  between  the 
benign  neoplasms  and  the  malignant  neoplasms.  In  chronic  lym- 
phatic leukemia,  as  in  the  presence  of  any  of  the  benign  tumors, 
the  life  of  the  patient  is  not  markedly  shortened ;  death  is  usually 
due  to  some  intercurrent  disease. 

Treatment.  No  satisfactory  treatment  has  yet  been  outlined. 
In  any  case,  the  diagnosis  should  be  made  carefully  from  the 
study  of  several  blood  counts.  Whatever  improvements  can  be 
made  in  the  diet  and  general  hygiene  should  be  made  and  thfe 
symptoms  relieved  according  to  the  condition  of  the  patient  as 
found  upon  examination. 


ACUTE  SPLENOMYELOGENOUS  LEUKEMIA 

Acute  spleno-medullary  leukemia  is  a  disease  of  the  spleen  and 
red  bone  marrow,  characterized,  clinically,  by  the  rapid  develop- 
ment of  high  fever,  cachexia,  pallor,  edema  and  very  rapid  enlarge- 
ment of  the  spleen  and  sometimes  of  the  lymph  nodes. 

The  etiology  of  the  condition  is  unknown.  It  usually  appears  in 
young  people.  The  increase  in  the  white  blood  corpuscles  may 
be  remarkable.  Remissions  are  rare,  during  which  the  white  cell 
count  may  drop  almost  to  normal  and  the  symptoms  may  be 
relieved  to  a  certain  extent.  Usually,  however,  the  condition  of 
the  patient  grows  steadily  worse  and  death  is  likely  to  occur  in  a 
few  months  from  the  onset  of  the  first  symptoms. 

The  red  cells  vary  from  3,000,000  to  5,500,000,  with  hemoglobin 
about  4.5  gr.  per  100  c.c,  or  about  34%  of  the  normal.  The  total 
leucocyte  count  may  run  very  low,  1,500  per  cu.  mm,  but  is  usually 
high,  to  500,000  per  cu.  mm.  Of  these,  myelocytes  are  most 
abundant,  reaching  99%  of  the  total  white  count,  in  some  cases. 


242  THE  LBUKBMIAS 

CHRONIC  SPLENOMYELOGENOUS  LEUKEMIA 

(Lienteric  leukemia;  spleno-medullary,  or  myeloid  leukemia) 

This  is  a  disease  of  the  blood  and  bone  marrow,  characterized 
clinically  by  insidious  onset,  vague  symptoms  leading  progressively 
to  death ;  and  by  the  occurrence  of  large  numbers  of  granular  leuco- 
cytes, especially  mononuclear  forms,  in  the  blood. 

Etiology.  The  cause  of  the  disease  is  unknown ;  it  may  follow 
malaria,  syphilis ;  wasting  infectious  disease,  as  typhoid ;  pregnancy 
in  women  or  the  climacteric  in  either  sex.  A  blow  over  the  spleen 
has  been  reported  in  some  instances;  gastric  or  intestinal  ulcers, 
and  stomatitis  may  precede  the  diagnosis;  but  not  necessarily  the 
beginning  of  the  disease. 

Lesions  aflFecting  the  ninth  and  tenth  thoracic  vertebrae  are 
constant. 

Diagnosis.  The  symptoms  are  vague;  the  onset  is  insidious 
and  slow.  Weakness  and  dyspnea,  irregular  fevers,  speedy  fatigue, 
occasional  diarrhea,  pallor,  nervous  irritability,  priapism,  insomnia 
with  tendency  to  drowsiness,  all  without  wasting,  perhaps  with 
increase  of  body  weight,  an  especially  large  abdomen,  are  the 
usual  symptoms.  The  diagnosis  must  be  made  upon  the  blood 
examination. 

Blood.  In  the  early  stages  the  red  cells  and  hemoglobin  remain 
almost  or  quite  normal.  Later,  both  are  reduced ;  the  hemoglobin 
first  and  most  rapidly;  the  color  index  is  usually  less  than  1,  and  is 
sometimes  very  low  (.5  or  even  less).  With  diminution  of  the 
hemoglobin,  poikilocytes  appear.  Later  microcytes,  normoblasts, 
vacuolated,  spherical  and  granular  red  cells  appear;  toward  the  end, 
megalocytes  and  megaloblasts  appear;  the  latter  presenting  imma- 
ture and  atavistic  characteristics.  The  most  important  changes  are 
in  the  white  cells.  The  total  count  is  from  15,000,  in  the  early 
stages,  to  500,000  or  more  in  the  later  stages  (more  than  800,000, 
in  one  P.C.O.  clinic  case).  The  increase  is  in  the  granular  cells, 
especially  the  neutrophiles.  The  eosinophiles  are  absolutely 
increased,  sometimes  relatively ;  the  basophiles  are  increased  both 
relatively  and  absolutely ;  amphophiles  are  usually  fairly  abundant. 
The  pathognomonic  finding  is  the  presence  of  considerable  num- 
bers of  myelocytes.  These  are  usually  of  the  neutrophilic  variety, 
and  may  make  up  25%  of  the  total  white  count. 

Basophilic,  eosinophilic  and  amphophilic  granular  myelocytes 
are  found;  near  the  termination  of  the  disease,  basophilic  myelo- 
cytes of  great  size,  resembling  those  of  the  acute  leukemias,  may 
be  found. 

During  the  progress  of  the  disease,  periods  occur  when  the 
actual  count  is  almost  or  quite  normal ;  occasionally  leucopenia 
occurs.    The  myelocytes  and  atavistic  forms  rarely  disappear,  how- 


HODGKIN'S  DISEASE  243 

ever,  and  in  doubtful  cases  the  blood  count  should  be  repeated  at 
intervals  of  a  week  or  a  few  weeks  until  the  diagnosis  is  clear. 

The  spleen  is  enlarged  in  every  case,  though  its  size  is  subject 
to  considerable  variation.  It  may  extend  into  the  pelvis  and  to 
the  right  iliac  crest;  the  abdomen  is  the  size  of  that  of  full  term 
pregnancy.  The  liver  is  also  larger  than  normal.  Lymph  nodes 
are  sometimes  enlarged.  Hemic  murmurs  may  be  found ;  the  pulse 
is  full  and  compressible. 

The  urine  shows  excess  of  uric  acid  and  other  nuclear  deriv- 
atives. 

Hemorrhages  may  appear  upon  the  mucous  membranes  or 
subcutaneously.    Death  may  be  due  to  internal  hemorrhage. 

Treatment.  The  correction  of  the  lesions  of  the  ninth  and  tenth 
thoracic,  raising  the  ribs,  and  the  study  and  correction  of  other 
causes  of  poor  circulation  through  the  abdominal  viscera  is  of 
most  importance,  and  has  seemed  to  be  eflfective  in  the  early  cases 
reported ;  it  is  important  that  complete  histories  with  blood  reports 
should  be  kept  of  such  cases.  In  the  late  cases,  symptoms  are 
relieved  and  life  apparently  prolonged  and  made  more  comfortable, 
as  the  result  of  corrective  measures.  The  patient  must  be  warned 
against  overexertion.  An  abundance  of  fresh  air,  a  plentiful  mixed 
diet,  and  quiet  living  are  essential  to  the  greatest  improvement. 
Extirpation  of  the  spleen  has  been  followed  by  relief  in  some  cases, 
by  immediate  symptoms  of  acute  leukemia  and  speedy  death  in 
others,  and  by  a  period  of  relief,  followed  by  later  acute  leukemia 
and  speedy  death  in  still  other  cases.  Death  from  shock  may 
occur  as  the  immediate  result  of  the  operation. 

Prognosis.  ,  In  early  cases,  with  comparatively  low  counts, 
recovery  may  be  hoped  for ;  in  later  cases,  recovery  is  doubtful  but 
improvement  is  to  be  expected ;  after  the  white  cell  count  exceeds 
200,000  and  myelocytes  are  abundant,  especially  if  hyaline  forms 
appear,  death  is  probably  inevitable  in  a  few  months.  Even  in 
these  cases,  however,  remissions  with  months  of  fairly  good  health 
may  be  hoped  for.  Death  is  preceded  by  some  days  of  great 
weakness,  dyspnea,  often  orthopnea.  The  mind  remains  unclouded 
until  increasing  weakness  leads  to  unconsciousness. 


HODGKIN'S  DISEASE 

(General  lymphadenoma ;  pseudo-leukemia) 
Hodgkin's  disease  is  sometimes  called  pseudo-leukemia.     It  is 
characterized  by  very  rapid  enlargement  of  the  lymph  nodes  of 
the  body  and  of  the  spleen,  usually  without  leukemia. 

The  cornybacterium  granulomatis  maligni  is  supposed  to  be  the 
specific  infectious  agent. 


244  THE  LBUKEMIAS 

The  diagnosis  rests  upon  the  generalized  enlargement  of  the 
lymphatic  glands  and  the  blood  examination.  An  increased  amount 
of  uric  acid  is  present  in  the  urine.  The  symptoms  are  vague  and 
not  usually  severe.  A  slight  weakness,  occasionally  dyspnea,  to- 
gether with  some  rheumatoid  symptoms,  are  all  that  are  usually 
present.    Fever  may  be  present,  irregularly,  rarely,  above  100. 

The  blood  shows  no  constant  changes.  Excess  in  the  large 
mononuclear  cells  and  the  myelocytes  are  frequent.  Platelets  are 
increased.  Masses  detached  from  the  pseudopodia  of  the  megalo- 
caryocytes  have  been  described.  (Bunting.)  Increase  in  the  white 
cell  count  usually  ?ippears  after  the  disease  is  well  advanced. 
Rarely  marked  leucocytosis  appears  early. 

The  progress  of  the  disease  is  slow  and  death  is  usually  from 
some  intercurrent  affection.  In  some  cases  a  rapidly  developing 
anemia  and  cachexia,  increasing  fever,  and  hemorrhages  cause  hasty 
death.  Rarely  lymphatic  leukemia  develops  from  Hodgins  disease; 
in  some  such  cases  it  is  probable  that  the  first  diagnosis  was  faulty. 

Treatment  is  commonly  unsatisfactory.  The  symptoms  may 
be  met  as  they  arise,  with  a  fair  degree  of  success. 

LEUKANEMIA.  Leukanemia  is  a  disease  of  the  blood,  characterized  by 
an  increase  in  the  white  blood  cells  in  toto,  associated  with  rapid  deterioration 
of  the  red  cells,  similar  to  that  observed  in  pernicious  anemia. 

The  disease  is  rapidly  fatal,  and  no  satisfactory  treatment  has  yet  been 
found  for  it 

APLASTIC  ANEMIA.  This  is  a  disease  of  youth  or  young  adult  life, 
more  frequent  in  women  than  men,  in  which  the  anemia  seems  to  be  due  to 
defective  blood  formation.  Autopsy  shows  the  red  bone  marrow  shrunken  and 
atrophied.  It  begins  insidiously  but  rapidly,  with  increasing  weakness  and 
dyspnea.  Hemorrhages  upon  the  mucous  membranes  and  skin,  and  into  internal 
organs  may  suggest  scurvy. 

The  red  cells  and  hemoglobin  are  about  equally  reduced;  no  normoblasts, 
megaloblasts,  or  poikilocytes,  or  other  indication  of  hurried  blood  formation  are 
present,  nor  do  the  red  cells  show  stippling,  unequal  staining  or  other  indica- 
tions of  toxin  presence.  The  granular  leucocytes  are  diminished  greatly,  while 
the  total  lymphocyte  counts  remains  practically  normal. 

The  course  rapidly  goes  on  to  death,  under  the  treatment  medically  indi- 
cated.   No  reports  have  been  made  by  osteopaths. 


PARTY 
DISEASES  OF  THE  URINARY  SYSTEM 


GENERAL  DISCUSSION 

The  kidneys  occupy  rather  a  peculiar  position  among  the  organs 
of  the  body.  Since  it  is  their  duty  to  secrete  from  the  blood  those 
substances  which  are  the  more  or  less  harmful  products  of  katabo- 
lism,  they  are  primarily  somewhat  more  resistent  to  the  action  of 
these  toxins  than  are  other  cellular  elements,  and  they  are  at  the 
same  time  subject  to  injury  when  the  blood  contains  foreign  ele- 
ments or  varies  to  any  great  extent  from  that  of  the  normal  body. 

The  kidneys  secrete  according  to  the  varying  qualities  of  the 
blood  and  the  varying  speed  of  flow  through  the  renal  capillaries. 
Generally  speaking,  the  higher  the  pulse  pressure,  the  greater  the 
urinary  flow. 

No  secretory  nerves  have  yet  been  demonstrated  for  the  kid- 
neys. The  vasomotor  nerves  for  the  kidneys  and  the  suprarenals 
are  derived  from  the  eleventh  and  the  twelfth  thoracic  segments 
of  the  spinal  cord.  Vertebral  or  costal  lesions  affecting  these 
segments  are  very  important  factors  in  modifying  the  circulation 
through  the  kidneys,  and  thus  their  secretion  and  nutrition. 

The  normal  constituents  of  the  urine  vary  widely,  under  normal 
as  well  as  under  abnormal  conditions.  The  following  abnormal 
findings  are  not  rare. 

Hematuria.  Blood  may  be  found  in  the  urine  in  small  quan- 
tities, as  the  result  of  most  forms  of  nephritis.  The  passage  of  a 
calculus  is  usually  associated  with  more  marked  hemorrhage. 
Blood  from  the  bladder  is  fresh  in  appearance.  The  red  blood 
cells  are  less  disintegrated  and  fragments  of  the  bladder  epithelium 
are  often  recognizable.  Fractional  catheterization  shows  blood 
increased  in  quantity  in  the  last  part  if  the  hemorrhage  is  in  the 
bladder,  in  the  first  part  if  the  hemorrhage  is  found  in  the  urethra, 
and  about  equally  through  all  parts  if  the  hemorrhage  is  from  the 
ureter  or  the  kidney. 

Hemoglobinuria.  When  the  hemoglobin  is  dissolved  out  of  the 
red  blood  cells,  it  is  speedily  eliminated  by  the  kidneys.  •  This  is 
the  case  after  the  use  of  certain  drugs,  in  malaria,  and  in  some 
other  blood  diseases. 

Albuminuria.  Albumin  is  eliminated  by  the  kidneys  chiefly  as 
the  result  of  disease  of  the  kidney  epithelium.  This  may  vary 
from  slight  hyperemia  to  very  severe  kidney  lesions.    As  a  tem- 

245 


246  THB  URINARY  SYSTEM 

porary  occurrence  and  in  small  quantities  the  presence  of  albumin 
in  the  urine  must  not  be  considered  a  very  serious  matter.  It  may 
be  the  result  merely  of  overtire,  or  possibly  from  an  orthostatic 
spinal  condition  (orthostatic  albuminuria).  It  should  always  arouse 
the  suspicion  of  a  kidney  disease  when  it  is  found,  and  the 
patient's  condition  be  the  subject  of  more  careful  investigation. 

Indicanuria.  This  occurs  most  commonly  as  the  result  of  intes- 
tinal putrefaction.  It  is  present  also  in  cancerous  cachexia,  in 
pus  accumulation  anywhere  in  the  body,  in  high  fevers,  and,  gen- 
erally speaking,  wherever  the  blood  is  absorbing  the  products  of 
proteid  decomposition. 

Pyuria.  Pus  is  present  in  the  urine  as  the  result  of  infection 
of  the  bladder  or  of  the  kidneys.  It  is  very  necessary  to  determine 
as  speedily  as  possible  the  source  of  the  pus.  In  women  the  possi- 
bility of  contamination  of  the  urine  from  a  vaginal  discharge  must 
not  be  forgotten.  In  men,  abscesses  which  drain  into  the  urethra 
are  to  be  considered.  Catheterization  should  eliminate  these  fac- 
tors. Catheterization  of  the  ureters  shows  which  kidney,  if  either, 
is  aflFected.  Injection  of  the  bladder  and  sometimes  of  the  ureter 
may  precede  the  X-ray  examination.  Without  this  injection  the 
X-ray  may  show  the  abscess  in  the  kidney  in  some  cases. 

Chyluria  is  a  rare  condition  in  this  country,  and  is  usually  due 
to  infection  by  the  filaria  sanguinus  hominis.    (q.  v.) 

Glycosuria.  Sugar  is  eliminated  in  the  urine  in  diabetes  mellitis 
(q.  V.)  and  also  as  the  result  of  the  overeating  of  sugar.  There 
seems  to  be  considerable  difference  in  the  sugar  toleration  of  dif- 
ferent individuals.  In  some  people  the  most  unbridled  eating  of 
candy  or  honey  does  not  seem  to  be  followed  by  glycosuria ;  in 
others  comparatively  small  amounts  of  carbohydrate  excess  give 
rise  to  glycosuria.  In  diabetes  mellitis,  certain  poisons,  long  fevers, 
and  other  conditions,  acetonuria,  diaceturia,  and  oxybutyria  are 
frequently  present.  These  are  of  more  or  less  serious  import, 
according  to  the  other  conditions  with  which  they  may  be  asso- 
ciated. The  occurrence  of  diacetic  acid  and  oxybutyric  acid  in  the 
urine  in  diabetic  patients  usually  precedes  the  onset  of  coma  and 
death. 

Other  Urinary  Constituents.  Calcium  oxalate  occurs  in  the 
urine  as  the  result  of  deficient  oxidization  processes.  Leucin, 
tyrosin,  and  cystin  are  usually  associated  with  diseases  of  the  liver. 
Echinococcus  booklets  may  be  found  in  the  urine  when  a  hydatid 
cyst  is  present  in  the  kidneys,  or  breaks  into  any  part  of  the  urinary 
tract.  The  urine  may  contain  various  infectious  agents,  as  the 
gonococcus  and  the  ordinary  pyogenic  bacteria,  molds  and  yeasts, 
and  certain  protozoa.  Such  findings  are  only  of  value  when  per- 
fectly fresh  urine  taken  under  aseptic  conditionsjs  examined. 


CHAPTER  XXV 
DISEASES  OF  THE  KIDNEYS 

ACUTE  HYPEREMIA 

(Active  hyperemia;  active  congestion) 

This  condition  may  be  the  first  stage*  of  acute  nephritis  or 
it  may  be  present  for  a  few  days  and  terminate  apparently  with 
recovery.  The  most  common  cause  of  the  condition  is  the  pres- 
ence of  irritating  substances  in  the  blood. 

Experiments  upon  animals  and  upon  healthy  individuals  show 
that  the  salts  of  all  the  common  metals,  including  sodium  chloride, 
the  immune  serums,  or  any  foreign  proteids  injected  into  the  cir- 
culation, or  any  of  the  active  medicines  in  common  use,  produce 
the  symptoms  of  active  hyperemia  of  the  kidneys,  increase  the 
multiplication  and  loss  of  the  renal  epithelium  and  thus  are  largely 
responsible  for  the  prevalence  of  renal  diseases  occurring  in  middle 
life.  The  gargling  of  potassium  chlorate  permits  small  quantities 
of  this  drug  to  be  swallowed;  the  application  of  turpentine  stupes 
and  the  giving  of  alcohol  rubs  permit  certain  amounts  of  these 
drugs  to  be  breathed  into  the  lungs  or  absorbed  into  the  blood; 
and  it  has  been  shown  conclusively  that  even  these  small  quan- 
tities of  irritating  drugs  act  upon  the  kidney  epithelium  to  a  cer- 
tain slight,  but  irreparable  extent.  Most  of  the  acute  infectious 
diseases  are  associated  with  kidney  symptoms.  Prolonged  expos- 
ures to  cold  and  focal  infections  are  factors. 

Lesions  of  the  tenth  to  the  twelfth  thoracic  vertebrae  and  the 
corresponding  ribs  are  etiologic  factors. 

Nephrectomy  of  the  opposite  kidney,  blocking  of  the  opposite 
ureter,  or  Dietl's  crisis  on  the  opposite  side,  produce  active  hyper- 
emia, probably  of  reflex  origin  and  similar  to  that  produced  by  a 
blow  upon  the  back,  or  by  suddenly  produced  bony  lesions  of  the 
dorso-lumbar  area. 

Diagnosis.  The  symptoms  are  not  pronounced.  There  may  be 
a  dull  pain  in  the  loin,  a  slight  feverishness  and  a  slightly  increased 
pulse  rate.  The  urine  is  scanty  with  no  marked  variation  in  the 
total  elimination  of  the  ordinary  solids.  A  few  blood  cells,  a  few 
hyalin  casts,  a  trace  of  albumin  and  some  cells  from  the  kidney 
tubules  are  present. 

Treatment.  First,  all  irritating  drugs  must  be  stopped;  bony 
lesions  as  found  must  be  corrected ;  the  lower  ribs  should  be  raised ; 
and  whatever  contracted  muscles  are  found  should  receive  atten- 

247 


248  THE  KIDNEYS 

tion.    Free  drinking  of  water  is  to  be  encouraged.    This  may  have 
lemon  juice,  or  any  other  fruit  juice,  added  to  it,  and  may  be  either 
hot  or  cold.    A  free  milk  diet  is  good.    Tea,  coffee,  alcohol,  spices, 
meats  are  to  be  omitted  from  the  diet  until  recovery. 
Most  cases  recover  in  a  few  days  under  this  treatment. 

PASSIVE  HYPEREMIA 

(Chronic  or  passive  congestion) 

Most  commonly  passive  congestion  of  the  kidney  is  due  to  the 
ordinary  causes  of  venous  interference,  such  as  mitral  lesion  or 
cirrhosis  of  the  liver.  The  kidney  is  large  and  purple  presenting  the 
appearance  called  cyanotic  induration.  Direct  pressure  upon  the 
renal  veins  may  be  caused  by  abdominal  tumors,  pregnancy,  ascites, 
visceroptosis,  and  other  somewhat  less  frequent  conditions.  Rarely 
thrombosis  or  embolism  of  the  renal  vein  may  be  responsible  for 
passive  hyperemia.  Nephroptosis  may  occur  as  part  of  Glenard's 
disease  or  it  may  exist  independently  and  be  a  cause  of  passive 
congestion. 

The  symptoms  of  passive  congestion  include  a  rather  constant 
dull  aching  in  the  loins;  scanty,  highly  colored  urine,  which  may 
contain  small  quantities  of  blood,  albumin,  casts,  renal  epithelium, 
and  an  excess  of  uric  acid;  to  these  symptoms  must  be  added  all 
those  due  to  the  cause  of  the  hyperemia. 

Treatment.  The  removal  of  the  cause  of  the  congestion,  if  this 
is  possible,  is  the  first  need.  Palliative  treatment  is  of  value  in  all 
cases.  This  includes  the  treatment  already  advised  for  active 
hyperemia,  together  with  such  measures  for  the  relief  of  the  circula- 
tory embarrassment  as  may  be  indicated.  It  may  be  necessary,  in 
passive  congestion,  to  reduce  the  amount  of  water  taken  into  the 
body  to  a  certain  extent. 

ACUTE  NEPHRITIS 

(Acute   Bright's    disease;    acute    diffuse    nephritis;    catarrhal   nephritis;    acute 

parenchymatous  nephritis ;  including  glomerular  and  tubal  acute 

nephritis;  and  acute  productive  and  desquamative  nephritis) 

Acute  nephritis  is  inflammation  of  the  kidneys,  usually  of  sud- 
den onset,  and  characterized  by  some  pain  and  gastro-intestinal 
symptoms,  diminished  urine  with  varying  amounts  of  albumin  and 
casts. 

Etiology.  Acute  nephritis  may  appear  at  almost  any  time  of 
life.  It  is  due  to  changes  in  the  circulation  of  the  blood  or  to 
toxic  or  infectious  elements  in  the  blood. 

The  bony  lesions  are  factors  in  producing  acute  nephritis. 
Blows  or  strains  affecting  the  eleventh  and  twelfth  thoracic  ver- 


I 


ACUTB  NEPHRITIS  249 

tebrae  and  the  corresponding  ribs  are  important.  Lordosis  is  gen- 
erally recognized  as  a  cause  of  albuminuria  and  is  a  predisposing 
cause  of  acute  nephritis.  Irritants  in  the  blood  include  alcohol, 
which  is  very  efficient  in  producing  nephritis;  certain  drugs,  espe- 
cially turpentine,  the  coal  tar  derivatives,  cantharides,  ether  and 
others.  The  bacterial  diseases,  especially  the  exanthemata,  are 
usually  associated  with  acute  nephritis,  but  the  protozoan  diseases, 
such  as  malaria  and  syphilis,  rarely  cause  the  acute  form.  Injury 
to  the  skin,  such  as  result  from  severe  burns,  poison  oak,  trauma, 
may  cause  nephritis.     Exposure  to  cold  may  be  responsible. 

Pathology.  The  kidney  shows  more,  or  less  localized  areas  of  in- 
flammation ;  the  affected  cells  are  undergoing  granular  Regeneration ;  the  cap- 
sule is  somewhat  adherent;  and  the  entire  kidney  slightly  increased  in  size. 
Other  organs  of  the  body  show  the  effects  of  the  edema.  Special  varieties  are 
described  according  to  the  locality  affected. 

Glomerular  Nephritis  is  found  most  frequently  in  scarlet  fever  and 
diseases  of  somewhat  similar  character.  The  inffammation  may  be  rather  strictly 
localized  in  the  glomeruli  in  this  form.  Edema  is  practically  invariable  in  the 
glomerular  form. 

Tubular  Nephritis  is  especially  due  to  alcohol  or  other  forms  of 
poison.  The  inflammation  of  the  tubules  is  somewhat  less  strictly  locahzed  than 
is  the  case  in  the  glomerular  form.     Edema  is  sometimes  slight  or  absent. 

Diffuse  Nephritis  involves  not  only  glomeruli  and  tubules,  but  also  the 
interstitial  tissues. 

Hemorrhagic  Nephritis  is  especially  characterized  by  the  presence  of 
blood  in  the  urine  and  the  occurrence  of  numerous  small  hemorrhagic  foci  in 
the  kidneys. 

Acute  Productive  Nephritis  is  characterized  by  rapid  multiplication  of 
the  connective  tissues  in  localized  areas  of  the  kidney  which  results  in  the 
formation  of  wedge-like  areas  of  fibrous  tissue.  It  is  somewhat  more  speedily 
fatal  than  are  other  acute  forms. 

Lymphomatus  Nephritis  is  an  acute  form  which  is  characterized  by 
marked  lymphocytic  and  leucocytic  infiltration  of  the  intermediate  zone  of  the 
kidney. 

Diagnosis.  The  symptoms  of  acute  nephritis  are  sometimes 
typical  and  sometimes  easily  confused  with  gastro-intestinal 
attacks.  Chilliness  followed  by  a  slight  fever  with  nausea,  some- 
times vomiting  and  pain  in  the  loins  or  sometimes  between  the 
shoulders,  is  characteristic ;  a  puffiness  under  the  eyes,  sometimes 
in  the  lids,  and  a  generalized  swelling  of  the  face,  usually  occurs 
rather  early;  the  skin  becomes  pale  and  waxy-looking;  later  the 
ankles,  and  following  this  the  legs  and  other  parts  of  the  body  are 
affected ;  ascites  may  be  marked  and  the  external  genital  organs  are 
frequently  enormously  distended ;  the  highly  concentrated  urine 
may  irritate  the  bladder  and  urethra  to  such  an  extent  as  to  initiate 
cystitis. 

The  occurrence  of  any  of  these  symptoms,  even  if  edema  is 
absent,  should  cause- an  examination  of  the  urine  to  be  made.  The 
.total  quantity  is  diminished  in  acute  nephritis,   sometimes   even 


250  THE  KIDNEYS 

complete  suppression  may  occur;  the  color  is  dark,  the  specific 
gravity  high ;  there  may  be  marked  cloudiness  from  the  presence 
of  the  anatomical  elements;  albumin  may  reach  1%  or  1.5%,  or  may 
be  absent;  renal  epithelium,  red  and  white  blood  corpuscles,  and 
cells  from  the  bladder  may  be  present ;  casts  may  be  hyalin,  blood, 
epithelial,  or  granular,  all  forms  may  be  present  in  a  single  speci- 
men; the  urea  and  the  normal  inorganic  constituents  are  dimin- 
ished. 

The  onset  of  uremia  is  marked  by  visual  disturbances,  headache, 
backache,  vomiting  and  convulsions. 

Treatment.  The  consideration  of  the  causes  of  nephritis  in 
any  given  case  should  determine  to  a  certain  extent  the  methods 
of  treatment  employed.  All  irritants  must  be  omitted  from  food 
and  drink;  alcohol,  tea,  coflfee,  tobacco,  meats,  spices,  are  to  be 
forbidden ;  a  strict  milk  diet  is  by  far  the  best  thing.  During  the 
acute  attack  rest  in  bed  is  necessary;  very  free  drinking  of  hot 
water  is  to  be  encouraged. 

Treatment  should  be  given  twice  each  day  during  the  presence 
of  the  acute  symptoms,  later,  less  frequently.  The  mobility  of  the 
lower  thoracic  and  upper  lumbar  spinal  column  should  be  increased; 
reflex  muscular  contractions  of  the  dorso-lumbar  region  should  be 
corrected ;  the  ribs  raised ;  and  whatever  lesions  may  be  found  are 
best  corrected  as  speedily  as  possible. 

Prolonged  sweating  is  useful  so  long  as  this  does  not  weaken 
the  patient.  Colonic  irrigation  may  be  useful ;  it  may  be  con- 
tinued for  hours,  in  severe  cases.  The  urine  should  be  examined 
carefully  and  frequently. 

After  recovery  from  the  acute  attack,  the  patient  should  return 
for  examination  and  for  urinalysis  at  intervals  of  a  few  weeks,  in 
order  that  the  occurrence  of  the  chronic  form  may  be  avoided. 

Prophylaxis.  Acute  nephritis  may  be  avoided  by  using  a  good 
wholesome  diet;  by  the  correction  of  lesions  of  the  eleventh  and 
twelfth  thoracic  vertebrae,  especially  by  the  avoidance  of  alcohol 
and  of  exposure  to  cold.  During  the  acute  infectious  diseases  the 
treatment  of  the  dorso-lumbar  areas  goes  far  toward  preventing 
the  occurrence  of  nephritis.  The  urine  should  be  watched  and  the 
first  appearance  of  albuminuria,  casts,  or  renal  epithelium  should 
be  followed  by  vigorous  treatment. 

Prognosis.  Recovery  usually  occurs  within  one  to  three  weeks. 
If  the  cause  of  nephritis  persists,  the  condition  may  pass  into  the 
chronic  form. 

KIDNEY  OF  PREGNANCY 

The  typical  kidney  of  pregnancy  precedes  eclampsia,  as  a  general  thing, 
and  is  a  toxic  tubular  nephropathy.  The  toxins  produced  by  the  fetal  metab- 
olism are,  for  some  unknown  reason,  retained  within  the  body  in  an  apparently 


CHRONIC  NEPHRITIS  251 

virulent  form ;  the  kidney  tubules  suflFer  markedly,  while  the  glomeruli  are  little 
aflfected.  With  the  emptying  of  the  uterus,  the  kidney  condition  is  immediately 
relieved. 

Women  who  have  had  acute  glomerular  nephritis,  or  in  whom  the  causes 
of  glomerular  nephritis  exist,  are  apt  to  suffer  exacerbations  of  this  disease 
during  pregnancy.  Emptying  the  uterus  may  give  relief,  but  the  kidney  disease 
may  go  on  to  death  days  or  months  after  child  birth. 

The  treatment  is  that  of  acute  nephritis  (q.  v.)  with  the  modifications 
indicated  by  the  state  of  pregnancy.  The  urine  should  be  analyzed  at  intervals 
through  pregnancy,  whether  symptoms  of  renal  disturbance  appear  or  not. 


CHRONIC  PARENCHYMATOUS  NEPHRITIS 

(Chronic  Bright's  disease;  chronic  exudative  nephritis;  including  chronic  tubal, 

chronic  glomerular,  and  chronic  diffuse  nephritis ;  large  white 

kidney;  small  white,  or  contracted  kidney) 

This  is  an  inflammatory  process,  involving  chiefly  the  glomeruli 
and  the  tubules  of  the  kidney,  and  only  secondarily  the  interstitial 
connective  tissue. 

Pathology.  The  large  white  kidney  is  present  in  the  earlier  stages  of  the 
disease.  It  is  paler  than  normal;  the  capsule  is  not  usually  adherent;  on 
section,  the  kidney  presents  a  yellowish  color,  with  areas  of  congestion  or 
hemorrhage.  There  is  some  overgrowth  of  the  connective  tissue,  especially  in 
Bowman's  capsule. 

The  small  white  kidney  may  follow  that  just  mentioned,  as  the  result  of 
the  contraction  of  the  newly  formed  connective  tissue.  The  capsule  is  adherent 
over  considerable  areas;  there  are  fatty  degeneration  and  atrophy  of  the  glo- 
meruli and  tubules  and  the  interstitial  connective  tissue  is  increased.  Occa- 
sionally, waxy  degeneration  may  be  present. 

Another  form  of  kidney  is  that  called  the  large  red  kidney,  which  is  present 
in  chronic  hemorrhagic  nephritis.  In  this  type  the  hemorrhagic  foci  are  fol- 
lowed by  cicatrices;  the  contraction  of  these  leads  to  a  pitting  of  the  surface 
of  the  kidne}',  which  thus  presents  a  distinctly  bumpy  appearance.  On  section, 
the  kidney  is  seen  to  be  mottled  with  brown  areas  resulting  from  the  earlier 
hemorrhages. 

Etiology.  This  form  of  nephritis  may  follow  repeated  attacks 
of  the  acute  disease,  or  it  may  begin  slowly.  It  is  usually  the 
result  of  irritations,  of  a  mild  degree,  more  or  less  constantly 
present.  It  is  certainly  due  in  a  considerable  number  of  cases  to 
the  habitual  use  of  drugs. 

The  kidney  recovers  from  injury  by  the  multiplication  of  the 
cells  left  intact.  Any  of  the  salts  of  the  common  metals,  any  drug 
which  affects  any  of  the  secretions  of  the  body,  the  poisons  asso- 
ciated with  any  of  the  bacterial  infections,  and  the  serums  used  in 
the  treatment  of  some  of  these,  have  all  been  shown  to  cause 
loss  of  kidney  epithelium,  and  this  loss  is  repaired  by  the  multipli- 
cation of  the  cells  already  present  in  every  case.  The  kidney 
epithelium  has  only  a  limited  power  of  reproduction  and  while  it  is 
true  that  slight  injuries,  such  as  may  be  due  to  the  factors  just 
mentioned,  are  followed  by  apparently  complete. repair,  it  is  also 
true  that  such  demands  for  multiplication  cannot  be  indefinitely 


252  THE  KIDNEYS 

met.  When  repeated  irritation  has  exhausted  the  power  of  a 
considerable  portion  of  the  renal  epithelium  to  repair  itself  through 
the  multiplication  of  its  parenchymatous  cells,  the  phenomena  of 
acute  parenchymatous  nephritis  become  marked  and  usually  serious^ 
The  place  of  bony  lesions  in  the  etiology  of  this  form  of  nephri- 
tis is  probably  twofold.  In  the  first  place,  lesions  affecting  the 
eleventh  and  twelfth  thoracic  segments  of  the  cord  interfere  with 
the  normal  vasomotor  control  of  the  kidneys  and  thus  render  them 
more  easily  injured  and  less  well  nourished ;  bony  lesions  affecting 
the  centers  controlling  the  action  of  the  liver,  spleen  and  intestines, 
may  result  in  the  accumulation  of  the  toxic  products  of  katabolism 
within  the  body,  and  these  toxins  are  important  sources  of  irrita- 
tion to  the  kidney  glomeruli  and  tubules. 

Diagnosis.  The  symptoms  of  acute  nephritis  may  be  con- 
tinued in  a  somewhat  less  pronounced  form  into  the  general  symp- 
toms of  chronic  nephritis.  In  other  cases  the  disease  begins  with 
subacute  symptoms  from  which  recovery  does  not  occur.  Usually 
the  earlier  symptoms  in  this  disease  do  not  suggest  a  kidney  com- 
plication— a  progressive  loss  of  appetite,  with  increasing  weak- 
ness, some  nausea,  attacks  of  acute  gastritis,  and  varying  head- 
ache which  rarely  completely  disappears.  Examination  of  the 
urine  during  this  time  should  lead  to  the  diagnosis ;  too  frequently, 
however,  urinalysis  is  postponed  until  the  appearance  of  edema; 
this  frequently  affects  only  the  eyes  and  the  ankles  at  night  for 
some  time;  later  the  area  extends  over  more  or  less  of  the  entire 
body,  and .  it  may  be  so  pronounced  that  the  patient  is  almost 
unrecognizable;  the  complexion  assumes  a  pallid,  pasty  appear- 
ance, and  appears  translucent.  Death  may  result  from  edema  of 
the  larynx  or  the  lungs,  by  the  embarrassment  of  the  heart  directly, 
or  as  the  result  of  hydropericardium ;  or  the  disease  may  terminate 
by  the  appearance  of  uremic  symptoms — these  include  headache, 
nausea,  vomiting,  diarrhea,  dizziness,  and  insomnia,  which  go  on 
to  delirium,  coma  and  death. 

The  analysis  of  the  urine  should  be  repeated  at  intervals  of  a 
few  days,  in  order  that  the  actual  condition  of  the  metabolism  of 
the  body,  as  well  as  of  the  kidneys  may  be  determined.  The  total 
quantity  is  diminished  at  first;  in  later  stages  it  may  be  nearly  or 
quite  normal  in  quantity ;  and  during  the  time  when  the  exudates 
are  being  absorbed,  the  total  quantity  may  be  considerably 
increased.  The  albumin  is  very  high,  sometimes  reaching  3%  by 
Esbach's  test;  the  total  daily  quantity  of  normal  constituents  is 
diminished;  the  urine  is  turbid  and  dark  in  color;  blood  cells,  all 
forms  of  casts  and  granular  debris  are  present. 

Treatment.  The  treatment  consists  first  in  removing  the  causes 
of  toxemia.  Constant  attention  to  diet  and  hygienic  living  is 
necessary.     Whatever  treatment  is  indicated  by  an  examination 


CHRONIC  NEPHRITIS  253 

of  the  spinal  column  especially  in  the  region  of  the  eleventh  and 
twelfth  thoracic  vertebrae  should  be  given  and  this  should  be 
repeated  at  rather  frequent  intervals  for  several  weeks.  The  treat- 
ment for  acute  nephritis  may  be  employed. 

Probably  in  no  other  disease  than  nephritis  is  definite  adjust- 
ment of  the  vertebrae  corresponding  to  the  renal  segments  more 
urgent.  Frequently  specific  adjustment  of  this  region  is  almost 
immediately  followed  by  definite  improvement  in  renal  function- 
ing. Owing  to  marked  ligamentous  changes  it  is  ofttimes  difficult 
to  secure  thorough  release  of  the  parts.  Then  again  lesions  lower 
down  in  the  spine  or  innominata,  and  even  ones  higher  up,  may 
play  a  primary  role  in  so  far  as  the  maladjustments  are  concerned. 
The  corresponding  ribs  should  also  be  released.  All  of  this  should 
be  considered  in  conjunction  with  syphilitic,  streptococcus  and 
other  infections,  metabolic  toxins,  alcoholism,  and  the  general 
hygiene  that  makes  up  the  daily  habits  of  the  patient. 

Prognosis.  Complete  recovery  from  chronic  parenchymatous 
nephritis  is  rare,  though  many  of  the  subacute  cases  recover  pro- 
vided thorough  attention  to  spinal  lesions,  intestinal  hygiene  and 
elimination  of  all  infective  processes  is  instituted.  The  best  that 
can  be  hoped  from  treatment  in  serious  cases  is  to  delay  the 
inflammatory  process  and  to  give  what  parts  of  the  kidney  may 
be  left  the  best  opportunity  for  doing  good  work.  It  seems  that 
the  nephritis  associated  with  scarlet  fever  is  of  special  virulence. 

The  results  of  osteopathic  treatment  during  the  time  when  the 
kidney  is  large  or  normal  in  size  are  very  good.  In  many  cases  a 
symptomatic  cure  has  been  reported;  this  means,  no  doubt,  that 
with  a  good  circulation  and  nervous  control,  the  parts  of  the 
kidney  which  remain  intact  are  perfectly  able  to  meet  all  of  the 
ordinary  requirements  of  the  body.  Such  patients  should  be 
warned,  however,  that  a  certain  amount  of  their  kidney  tissue  has 
been  injured  as  the  result  of  the  disease  and  that  they  should  pay 
special  attention  to  their  habits  of  living  if  they  wish  to  live  the 
long  and  happy  and  useful  lives  to  which  they  are  entitled. 

CHRONIC  INTERSTITIAL  NEPHRITIS 

(Chronic  non-exudative  nephritis;  chronic  Bright's   disease;   cirrhotic  kidney; 
primary,  genuine,  contracted,  red,  glomerular,  or  gouty  kidney) 

Chronic  interstitial  nephritis  is  an  inflammation  chiefly  affect- 
ing the  connective  tissue  of  the  kidney  and  associated  with  degen- 
eration and  atrophy  of  the  parenchymatous  cells.  Cardio-vascular 
changes  are  always  marked  in  this  disease. 

Pathology.  Several  varieties  of  pathological  change  are  described  in 
connection  with  chronic  interstitial  nephritis. 

In  the  primary  form  of  the  disease,  the  kidneys  are  red  in  color  and  very 
small,  both  kidneys  together  may  weigh  less  than  three  ounces ;  the  capsule  is 


254  THE  KIDNEYS 

much  thickened  and  very  adherent;  the  kidney  itself  is  brown  in  color,  finely 
granular,  containing  many  cysts;  the  connective  tissues  are  greatly  increased 
in  quantity,  and  are  hardened  and  shrunken ;  the  parenchymatous  cells  show 
granular,  fatty,  or  waxy  degeneration,  as  well  as  atrophy.  In  gouty  patients, 
deposits  of  sodium  urate  and  other  uric  acid  compounds  may  be  present.  When 
the  condition  is  secondary  to  arteriosclerosis,  the  vessels  of  the  kidney  show 
more  marked  changes,  while  the  capsule  is  less  adherent  and  less  thickened. 
While  the  surface  of  the  kidney  is  smoother  in  the  typically  senile  form,  the 
entire  kidney  takes  part  in  the  atrophy,  the  capsule  is  very  thick  and  adherent, 
and  both  the  cortex  and  pyramids  are  rather  uniformly  atrophied.  There  is, 
in  the  senile  form,  a  marked  increase  in  the  pelvic  fat. 

Etiology.  The  causes  of  chronic  interstitial  nephritis  are  many ; 
yet  the  real  nature  of  the  underlying  etiology  is  vag^e.  Paren- 
chymatous nephritis  is  always  associated  with  more  or  less 
marked  interstitial  inflammation  and  this  may  go  on  to  so  great 
an  extent  that  the  interstitial  changes  ultimately  mask  the  primary 
parenchymatous  affection. 

With  the  onset  of  old  age  there  is  a  tendency  to  overgrowth 
and  contraction  and  toughening  of  all  connective  tissues  in  the 
body.  These  changes  are,  in  the  case  of  the  kidney,  merely  a 
part  of  the  general  onset  of  senility.  Heredity  is  certainly  a 
cause  of  interstitial  nephritis,  as  it  is  of  interstitial  inflammations 
and  premature  senility  of  the  entire  body. 

A  part  of  the  phenomena  associated  with  senility  is  found  in 
the  progressive  rigidity  of  the  articular  tissues.  This  is  asso- 
ciated with  a  posterior  curve  in  the  upper  thoracic  region,  and  a 
bending  forward  of  the  head  and  neck.  The  lower  limit  of  thi$ 
posterior  upper  thoracic  curve  usually  comes  at  about  the  ninth 
thoracic  segment.  A  somewhat  increased  mobility  in  this  region 
is  followed  by  rigidity  of  the  tenth  thoracic  and  throughout  the 
remainder  of  the  spinal  column.  In  some  cases  the  whole  spinal 
column  is  uniformly  rigid. 

The  effects  produced  by  this  rigidity  are  several — the  activities 
of  the  liver,  perhaps  the  spleen,  certainly  the  intestinal  tract,  are 
somewhat  diminished ;  the  power  of  these  organs  to  neutralize 
poisons  is  correspondingly  lessened ;  this  results  in  more  or  less 
toxemia.  The  nervous  control  of  the  vessels  of  the  kidneys  is 
also  impeded.  In  other  ways  the  accumulation  of  the  more  or 
less  toxic  products  of  katabolism  is  rendered  inevitable.  The  rigid 
thorax  is  not  associated  with  proper  habits  of  breathing.  Cardiac 
difficulties  complicate  the  picture.  All  of  these  things  are  more  or 
less  directly  due  to  the  rigid  spinal  condition. 

The  protozoan  infections,  such  as  syphilis  and  malaria ;  habitual 
alcoholism,  especially  what  is  ordinarily  called  "moderate"  drink- 
ing; the  overuse  of  proteid  foods,  and  overeating  of  too  great  a 
variety  of  complicated  foods ;  are  certainly  causes  of  this  condition. 
Too  little  exercise  and  excessive  exposure  to  cold,  damp  climates ; 
gout,  and  rheumatism  are  also  important  factors.     Like  senility, 


CHRONIC  NEPHRITIS  255 

gout,  and  several  of  the  causes  already  mentioned,  interstitial 
nephritis  seems  to  be  favored  by  the  general  conditions  of  modern 
civilized  life,  with  all  that  is  associated  with  that  term.  Strepto- 
coccus infection  (e.  g.,  tonsillitis)  by  way  of  the  blood  stream  prob- 
ably plays  an  important  role  in  certain  cases. 

Diagnosis.  The  symptoms  may  be  latent  for  many  years,  dur- 
ing which  the  kidney  changes  are  being  gradually  produced.  Not 
rarely  the  kidney  disease  remains  unsuspected  until  some  pul- 
monary or  cardiac  or  hepatic  disease  is  forced  to  a  fatal  termination 
by  the  sudden  exacerbation  of  the  kidney  difficulty.  Post-mortem 
examination  of  such  kidneys  shows  that  disease  has  been  slowly 
progressing,  though  unrecognized,  for  many  years. 

Occasionally  the  first  symptoms  are  those  of  uremia — head- 
-ache,  nausea,  vomiting,  dyspnea,  visual  disturbances,  convulsions 
or  stupor,  ending  in  coma  and  death,  or  slow  recovery.  Sometimes 
the  symptoms  are  more  gradual,  and  include  failing  vision,  sleep 
disturbances,  disordered  digestion,  sometimes  frequent  micturition. 
This  state  m.ay  go  on  slowly  for  some  years,  and  it  may  be  inter- 
rupted by  uremic  attacks.  The  urine  is  usually  considerably 
increased ;  the  hyperacidity  of  the  urine  leads  to  bladder  disturb- 
ances, which  may  cause  considerable  annoyance ;  the  daily  quantity 
may  reach  a  gallon  or  more ;  the  specific  gravity  may  be  as  low 
as  1002;  albumin  may  be  absent  or  present  in  mere  traces;  the 
total  elimination  of  solids  and  urea  is  considerably  diminished. 
The  low  urea  is  an  important  factor  in  diagnosis  and  prognosis. 
Red  and  white  blood  cells,  hyalin  and  granular  casts  are  found 
with  difficulty.  The  indistinct  urinary  findings  may  cause  the 
diagnosis  to  be  considerably  delayed. 

The  circulatory  disturbances  include  a  high  blood  pressure, 
sometimes  exceeding  200  mm.  of  Hg.  The  arteries  are  hard, 
thickened,  and  sometimes  tortuous.  Not  all  of  the  arteries  are 
equally  affected,  and  in  examining  the  condition  of  the  vascular 
system  the  radial,  temporal,  carotid,  and  other  accessible  arteries 
should  be  palpated.  The  heart  is  hypertrophied;  the  aortic  sound 
accentuated.     Cardiac  asthma  may  be  present. 

The  respiratory  disturbances  include  dyspnea,  sometimes  with 
signs  of  hydrothorax.  Epistaxis  may  be  the  first  symptom.  Orthop- 
nea and  Cheyene-Stokes  breathing  are  present  in  the  later  stages. 

The  nervous  symptoms  include  drowsiness,  which  may  be  asso- 
ciated with  marked  insomnia.  Apoplexy  may  be  the  first  sign  of 
the  condition.  Various  sensory  disturbances  may  be  present.  Ret- 
initis, partial  or  complete  blindness,  tinnitus  aurium,  and  fatigue 
may  be  early  symptoms.  The  retina  shows  characteristic  changes. 
Vomiting,  nausea,  diarrhea  are  the  most  prominent  digestive  dis- 
turbances. 

In  addition  to  the  edema,  which  is  not  usually  pronounced  in 
interstitial   nephritis,   the   skin   may    show   marked   dryness,   and 


256  THE  KIDNEYS 

occasionally  crystals  of  urea  are  found.  Cyanosis  and  pallor  are 
usually  present.  Pruritis  and  a  very  obstinate  eczema  are  very 
annoying  symptoms.  Uremic  attacks  may  appear  suddenly,  or 
uremia  may  come  on  gradually,  and  terminate  in  death. 

Treatment.  The  prophylaxis  of  interstitial  nephritis  must  be 
begun  some  forty  years  before  the  onset  of  the  disease.  A  good 
wholesome  way  of  living  and  eating  should  prevent  the  disease 
altogether.  Very  likely  syphilitic  (predisposing)  and  streptococcus 
infections  are  important  considerations. 

When  the  symptoms  appear,  the  patient  must  be  put  upon 
a  very  rigid  diet  and  daily  regime.  Exclusive  milk  diet  is  fre- 
quently of  value  for  a  short  time,  though  it  should  not  be  attempted 
to  puf  the  patient  upon  a  milk  diet  for  the  rest  of  his  life.  After 
a  preliminary  week  or  two  weeks  of  milk  and  fruit  juices  alone, 
he  may  begin  to  take  fruit,  vegetables  and  some  cereals.  He 
should  be  instructed  to  make  his  entire  diet  upon  vegetables,  fruits, 
milk,  with  only  very  small  amounts  of  sugar,  salt,  starch  or  meat. 
Indeed,  in  many  cases  these  four  articles  are  best  omitted  alto- 
gether. 

The  warm  dry  climates  are  best  and  it  is  frequently  of  value  to 
change  from  a  low  to  a  high  altitude  or  vice  versa. 

The  correction  of  the  spinal  rigidity,  which  is  universally  pres- 
ent, is  of  great  value.  Treatment  should  be  given  very  gently, 
with  movements  which  exert  no  recognizable  stimulation  upon  the 
nerve  centers.  It  is  best  in  the  beginning  to  give  treatments  every 
day,  or  every  other  day  until  the  spinal  column  and  the  ribs  show 
some  increased  mobility.  "  Still  do  not  neglect  definite  corrective 
work.  After  this,  treatment  should  be  given  three  times  each 
week,  then  twice,  then  once,  until  a  very  flexible  spinal  column  is 
secured.  After  this  the  patient  needs  to  return  for  examination 
and  perhaps  a  few  treatments  two  or  three  times  each  year. 

"Venesection  is  of  marked  benefit  in  uremia.  About  a  pint  of  blood 
should  be  taken,  under  aseptic  conditions,  from  a  large  Superficial  vein.  The 
sudden  lowering  of  venous  pressure  produced  in  this  way  often  causes  immedi- 
ate kidney  activity  and  relieves  the  toxemia  very  speedily,  far  better  than  the 
usual  sweating  and  other  methods." — McConnell. 

"In  addition  to  the  specific  osteopathic  treatment,  we  must  pay  close  atten- 
tion to  diet,  and  I  prefer  ordinarily  to  fast  the  patient  twelve  to  twenty-four 
hours,  following  it  with  as  nearly  a  milk  diet  as  the  patient  will  stand  for,  and 
later  add  some  vegetables,  spinach  and  lettuce — some  cereals,  eggs  and  fish  as 
the  case  progresses.  In  addition  to  this,  if  the  blood  pressure  be  not  too  high, 
showing  the  absence  of  arteriosclerosis,  I  believe  in  the  Turkish  baths,  because 
the  skin  is  one  of  the  chief  aids  in  elimination,  and  will  take  much  work  off 
of  the  kidneys.  I  prefer  to  have  the  patient  sleeping  in  the  open  air  as  in 
tuberculosis,  because  you  have  a  constitutional  disturbance,  and  you  increase 
the  oxidation  of  the  waste  materials  by  means  of  the  open  air  sleeping  and 
relieve  the  kidneys  of  that  much  work.  We  have  to  protect  these  cases;  ordi- 
narily I  advise  the  woolen  underwear  and  give  them  plenty  of  rest.  I  do  not 
believe  in  rest  in  the  recumbent  position  too  much,  for  then  we  have  too  much 
passive  hyperemia.    I  advise  alternating  the  upright  position  and  the  recumbent 


PYELITIS  257 

position.  The  use  of  salt  water  enemas  in  these  cases  is  helpful,  using  the 
normal  salt  solution  and  having  the  patient  take  from  one  to  two  quarts  of 
water  at  night  before  retiring  and  retaining  as  much  as  possible  over  night." — 
F.  H.  Smith. 

Prognosis.  The  diseased  kidney  tissue  cannot  be  restored.  On 
the  other  hand,  it  is  very  remarkable  how  great  efficiency  is  pos- 
sible to  badly  diseased  kidneys.  The  treatment  as  outlined  gives 
the  best  possible  circulation  through  the  kidneys  and  relieves  them 
to  as  great  a  degree  as  is  possible  of  the  burdens  that  they  have 
been  unfairly  compelled  to  bear  throughout  life.  If  the  patient  is 
obedient  and  cheerful,  he  should  be  able  to  live  his  life  out  in 
a  fairly  comfortable  manner.  If  he  fails  to  obey  instruction  or  if 
the  kidney  lesions  are  too  pronounced,  he  may  die  either  as  the 
result  of  the  associated  cardio-vascular  disease  or  from  uremia ; 
or  some  intercurrent  disease,  such  as  pneumonia  or  gastritis, 
may  be  fatal  on  account  of  the  kidney  lesion  rather  than  on  account 
of  its  own  severity. 

PYELITIS 

(Pyelo-nephritis;  pyonephritis) 

This  term  is  applied  to  inflammation  of  the  pelvis  of  the  kidney 
and  the  pyramids.  Also,  the  term  pyelo-nephritis  is  applied  to 
those  conditions  in  which  the  mass  of  the  kidney  is  recognizably 
involved. 

Pathology.  The  catarrhal  form  is  the  most  common.  A  pseudo- 
diphtheritic  inflammation  is  occasionally  present.  Tubercular  pye- 
litis is  occasionally  found.  Suppurative  pyelitis  is  usually  due  to 
metastasis. 

Etiology.  Pyelitis  rarely  occurs  as  a  primary  disease.  The 
most  frequent  cause  is  a  renal  calculus.  Gonorrheal  inflammation 
lower  in  the  urinary  tract  may  extend  upward  through  the  ureter 
to  the  pelvis  of  the  kidney,  especially  when  the  renal  circulation 
has  been  impaired.  The  colon  bacillus  may  be  responsible  for 
pyelitis  under  similar  circumstances.  Infections,  such  as  are  asso- 
ciated with  acute  nephritis,  or  renal  carcinoma  or  tuberculosis 
may  cause  pyelitis.  Occasionally  drugs  in  the  urine  may  inflame 
the  membranes  of  the  renal  pelvis. 

Diagnosis.  It  is  usually  diflicult  to  make  a  diagnosis  of  pyelitis 
except  as  the  causative  factors  are  recognized.  Sometimes  it  is 
possible  to  find  the  epithelium  from  the  pelvis  of  the  kidney  in 
the  urine.  It  is  usually  difficult  to  distinguish  these  from  the  cells 
of  the  inflamed  bladder. 

Pain  is  often  acute,  extending  down  the  ureters.  This  is  espe- 
cially severe  when  the  condition  is  associated  with  passage  of  a 
renal  calculus.    The  fever  may  be  very  irregular,  hectic  or  typhoid. 


258  THE  KIDNBYS 

Symptoms  resembling  those  of  uremia  rarely  occur.  Reflex  mus- 
cular contractions  of  the  lumbar  region  are  extremely  marked,  and 
hypersensitive  areas  are  usually  found. 

Treatment.  The  treatment  varies  according  to  the  cause  of  the 
disease.  If  the  X-ray  examination  shows  a  stone,  surgery  may 
be  indicated.  Free  drinking  of  water,  application  of  heat  and 
cold,  relaxation  of  the  lumbar  muscles,  adjustment  of  the  lower 
dorsal  and  lumbar  vertebrae  and  innominata,  are  all  important  fac- 
tors in  relieving  the  pain  and  promoting  recovery. 

Prognosis.  The  prognosis  depends  upon  the  associated  con- 
ditions. Purulent  cases  are  liable  to  infect  the  peritoneal  cavity 
and  cause  death. 

RENAL  NEUROSES 

All  attempts  toward  demonstrating  the  existence  of  nerves  directly  governing 
the  secretion  of  urine  have  failed.  On  the  other  hand,  the  secretion  of  urine 
is  known  to  depend  upon  the  rate  of  the  blood  flow  through  the  kidney;  this 
in  turn  depends  upon  the  difference  between  the  arterial  pressure  and  the  venous 
pressure,  and  also  upon  the  caliber  of  the  renal  arterioles.  Vasomotor  nerves 
to  the  kidney  have  been  demonstrated  by  different  observers.  These  are  de- 
rived from  the  eleventh  and  twelfth  thoracic  segments  of  the  spinal  cord.  The 
renal  splanchnic  nerves  .from  these  segments  pass  by  way  of  the  hypogastric 
plexus.  Gray  fibers  from  these  ganglia  and  from  the  aortic  plexus  pass  to  the 
blood  vessels  of  the  kidney. 

The  fact  that  the  kidneys  are  profoundly  affected  by  nervous  conditions 
is  shown  by  the  urinary  variations  associated  with  certain  nervous  diseases. 
For  example,  in  hysteria,  especially  after  a  crisis,  great  quantities  of  extremely 
pale  urine  of  low  specific  gravity  are  voided.  After  an  epileptic  attack,  on 
the  other  hand,  very  little  urine  is  secreted  for  some  hours.  Individuals  who 
undergo  any  nervous  shock,  excitement,  passion  of  any  kind,  suffer  from 
changes  in  the  urinary  secretion  and  these  are  most  commonly  like  those  found 
in  hysteria. 

Local  influences  which  act  upon  the  eleventh  and  twelfth  thoracic  seg- 
ments, including  both  acute  and  chronic  conditions  of  trauma,  such  as  a  blow 
across  the  back,  may  shock  these  nerve  centers,  so  that  urine  is  not  secreted 
for  some  time  after,  and  when  the  flow  again  begins,  it  may  be  scanty,  dark, 
of  high  specific  gravity,  and  may  sometimes  contain  blood,  casts  or  albumin. 
A  wrench  or  sudden  jar  may  have  the  same  effect. 

Bony  lesion  of  the  tenth  thoracic  to  the  first  lumbar  vertebrae  may  be 
responsible  for  disturbed  kidney  secretion.  It  seems  to  be  a  cause  of  chronic 
parenchymatous  nephritis,  and  also  it  increases  the  danger  of  renal  involvement 
during  the  presence  of  the  acute  infectious  diseases. 

In  every  case  of  renal  disturbance  it  is  very  important  that  the  nervous 
relationships  should  be  investigated.  Not  only  the  disturbed  structural  condi- 
tions, but  also  those  factors  associated  with  emotional  disturbance  must  be 
corrected,  if  the  patient  is  to  make  the  most  speedy  and  complete  recovery. 

RENAL  CALCULUS 

(Nephrolithiasis;  gravel,  renal  colic;  pyelitis  calculus) 
Renal  calculi  are  concretions  in  the  kidney  substance  or  in  the 
pelvis  of  the  kidney.     They  are  of  various  sizes  and  are  called 
renal  sand,  renal  gravel,  renal  stone,  or  calculus,  according  to  the 


I 


CALCULUS  259 

size  of  concretions.  When  the  stone  makes  a  mold  of  the  pelvis, 
it  is  called  a  coral  or  dendritic  calculus.  The  most  frequent  of 
these  stones  are  precipitates  of  uric  acid  and  the  urates.  Others 
are  composed  of  calcium  oxalate,  the  phosphates,  or,  rarely,  cal- 
cium carbonate  or  fatty  deposits.  Calcium  oxalate  calculi  are 
dark  and  very  irregular  in  size;  they  are  called  mulberry  calculi. 
The  presence  of  renal  calculi  is  usually  associated  with  varying 
degrees  of  pyelitis.  The  blocking  of  the  ureter  may  lead  to  hydro- 
nephrosis. 

Etiology.  The  cause  of  renal  calculus  is  not  very  well  known. 
It  is  most  frequent  in  children  and  in  old  people.  Men  suffer 
more  than  women.  Gout  and  the  hygienic  conditions  associated 
with  gout  seem  to  be  important  factors.  Those  conditions  which 
lead  to  the  elimination  of  an  excess  of  the  nitrogenous  wastes  in 
the  urine  seem  to  be  important  in  the  etiology  of  renal  calculus. 
Injuries  to  the  kidney  region  may  be  a  factor. 

Diagnosis.  The  symptoms  may  be  atypical.  The  passage  of  a 
stone  through  the  ureter  may  cause  most  agonizing  pain,  extend- 
ing downward  to  labia  or  penis,  which  begins  suddenly,  terminates 
suddenly,  and  is  followed  by  the  passage  of  the  stone  through  the 
urethra,  or  by  its  retention  within  the  bladder. 

A  stone  which  is  too  large  to  enter  the  ureter,  and  which  fits 
snugly  in  the  pelvis  of  the  kidney,  may  attain  tremendous  size 
with  no  symptoms  whatever.  The  most  important  diagnostic 
point  is  found  in  the  X-ray  plate. 

Treatment.  Hot  baths  and  hot  applications  to  the  loins  and 
over  the  abdomen,  the  free  drinking  of  hot  drinks,  and  very  strong 
pressure  over  the  tissues  near  the  lumbar  vertebrae,  may  be  suffi- 
cient to  relieve  the  pain,  so  that  the  stone  may  be  finally  passed 
into  the  bladder.  Its  passage  through  the  urethra  is  usually  less 
painful.  During  the  spasms  of  pain  of  renal  colic,  it  may  be  neces- 
sary to  use  chloroform  or  morphine. 

The  further  formation  of  gravel  or  stones  may  be  prevented  by 
a  nonpurin  diet,  and  by  free  water  drinking. 

When  an  incarcerated  pelvic  stone  is  recognized,  its  surgical 
removal  should  be  considered. 

Prognosis.  This  depends  upon  the  structural  conditions  asso- 
ciated with  the  presence  of  the  stone  and  upon  the  obedience  of 
the  patient  to  instructions  given  him  concerning  diet  and  habits 
of  living. 

AMYLOID  KIDNEY 

Amyloid,  waxy,  or  lardaceous  degeneration  of  the  kidney  is  associated  with 
a  similar  condition  existing  in  other  viscera. 

Pathology.  The  kidney  is  large,  pale,  usually  smooth,  and  sometimes 
marked   by   prominent   veins.     On    section,    the   kidney   presents   a   somewhat 


260  THE  KIDNEYS 

"bacon-like"  appearance.  The  usual  tests  for  amyloid  substance  give  positive 
results.  The  amyloid  change  usually  begins  in  the  walls  of  the  capillaries  of 
the  tufts.  The  disease  is  nearly  always  associated  with  a  diffuse  nephritis. 
Amyloid  disease  is  due  to  wasting  diseases — the  cachexias,  tuberculosis,  pro- 
longed suppuration,  especially  of  the  bones,  intestinal  ulcers,  and  many  other 
purulent  diseases.  It  is  frequently  present  in  tertiary  syphilis.  Less  frequently 
it  is  associated  with  uncompensated  heart  lesions,  leukemia,  gout,  or  malaria. 

Diagnosis.  The  symptoms  are  those  of  nephritis  and  are  frequently 
masked  by  the  symptoms  of  the  associated  disease.  The  urine  presents  few 
diagnostic  changes.  When  amyloid  casts  are  found  the  diagnosis  is  sure. 
Edema  is  occasionally,  but  not  always,  present. 

Treatment.  This  depends  upon  the  nature  of  the  causative  condition,  and 
is  rarely  of  much  value,  so  far  as  the  kidney  condition  is  concerned.  As  a 
rule,  the  condition  of  the  patient  is  hopeless  by  the  time  the  amyloid  disease 
of  the  kidney  is  recognizable. 

PERINEPHRIC  ABSCESS 

Suppuration  around  the  kidney  is  a  rather  rare  condition.  It  is  usually 
secondary  to  purulent  nephritis,  purulent  appendicitis,  or  abscess  of  the  liver. 
Occasionally  the  infectious  agent  is  carried  by  the  blood  from  distant  parts 
of  the  body. 

Diagnosis.  The  pain  characteristic  of  abscess  formation  is  located  in 
the  loin  on  the  affected  side,  and  may  extend  down  into  the  thigh,  or  up  into 
the  thorax.  The  thigh  on  the  affected  side  is  usually  flexed.  The  general 
symptoms  are  severe,  including  rigor,  fever,  heavy  sweating,  and  prostration. 
When  the  kidney  is  involved,  pus  may  drain  into  the  urine.  Otherwise,  no 
recognizable  changes  may  be  present.  As  the  pus  accumulates  the  tumor  be- 
comes palpable. 

The  treatment  is  surgical.  The  progfnosis  must  always  be  grave  and  the 
kidney  is  usually  permanently  damaged, 

HYDRONEPHROSIS 

This  is  an  accumulation  of  urine  in  the  pelvis  of  the  kidney. 
It  is  usually  unilateral. 

Pathology.  The  pelvis  of  the  kidney  is  dilated  and  the  pressure 
thus  exerted  upon  the  kidney  parenchyma  produces  variable  degrees  of  atrophy. 
The  pressure  upon  the  mucous  membrane  by  the  pelvis  and  calyces,  first  thins 
the  membrane  and  then  leads  to  a  marked  overgrowth  of  the  connective  tissue, 
which  supports  it.  The  fluid  which  is  retained  is  very  much  hke  diluted  urine. 
When  infection  occurs,  blood  and  pus  are  found  abundantly  in  the  retained 
liquid. 

Etiology.  The  condition  is  due  to  an  occlusion  of  the  ureter. 
It  may  be  congenital  or  it  may  be  due  to  impacted  calculus;  to 
cicatricial  stenosis  of  the  ureter ;  to  pressure  by  tumors,  pregnancy, 
or  adhesive  bands;  to  torsion  of  the  ureter,  as  in  floating  kidney; 
or  to  other  more  rare  causes  of  ureteral  occlusion. 

Diagnosis.  The  symptoms  are  not  distinctive.  There  may  be 
pain  in  the  loins  and  running  down  the  thigh.  Digestive  disturb- 
ances, often  with  diarrhea,  may  be  present,  or  obstinate  constipa- 
tion may  result  from  pressure. 


FLOATING  KIDNEY  261 

Physical  examination  shows  the  presence  of  a  tumor,  which 
may  be  elastic  or  fluctuating.  An  intermittent  form,  usually  due 
to  movable  kidney,  presents  many  difficulties  in  diagnosis.  The 
X-ray  should  show  the  location  of  the  impediment. 

Treatment.  Surgery  of  the  urinary  tract  is  always  difficult,  but 
this  represents  about  the  only  possibility  of  relief  in  hydronephro- 
sis. An  exception  to  this  statement  is  found  in  the  case  of  floating 
kidney,  (q.  v.) 

Prognosis.  Occasionally  the  pressure  of  the  urine  forces 
a  way  through  the  ureters.  Rarely  there  may  be  a  rupture  of  the 
sac.  In  those  conditions  in  which  the  obstruction  can  be  removed, 
the  prognosis  depends  upon  the  severity  of  the  causative  factors. 


FLOATING  KIDNEY 

(Ren  mobilis;  nephroptosis;  movable,  palpable,  dislocated,  or  wandering  kidney) 

The  kidney  is  held  in  place  rather  insecurely,  chiefly  by  means 
of  the  fat  in  which  it  is  imbedded.  When  for  any  cause,  it  is 
allowed  to  move  slightly  from  its  normal  position,  so  that  it  may 
be  palpated,  the  term  "palpable  kidney"  is  applied  to  it.  When 
its  change  of  position  is  sufficient  to  allow  its  upper  edge  to  be 
palpated,  but  it  does  not  fall  below  the  level  of  the  umbilicus,  the 
term  "movable  kidney"  is  used.  The  position  of  the  palpable 
kidney  and  the  movable  kidney  changes  with  deep  respiration. 

The  "floating,"  "wandering"  or  "dislocated"  kidney  can  be 
pushed  around  rather  freely  and  it  does  not  change  its  position 
with  deep  respiration. 

Etiology.  Lesions  of  the  dorso-lumbar  region  and  the  lower 
ribs  are  important  in  etiology.  By  far  the  most  common  cause  of 
floating  kidney  is  rapid  emaciation,  especially  following  a  period 
of  plumpness  or  obesity.  Increased  weight  of  the  kidney  due  to 
congestion  or  to  tumor,  such  as  hypernephroma,  are  rare  causes. 
Pregnancy,  tumors,  ascites,  tight  lacing,  are  all  somewhat  impor- 
tant factors  in  etiology.  Floating  kidney  may  be  a  part  of  the 
general  visceroptosis  of  Glenard's  disease. 

Diagnosis.  The  condition  is  recognized  by  palpation.  The 
patient  should  be  examined  in  various  positions;  as,  standing  with 
body  somewhat  bent  forward ;  lying  upon  the  table,  upon  his 
back,  side  and  face;  and  in  Sim's  position.  Other  changes  of  posi- 
tion may  permit  the  kidney  to  be  palpated  more  readily. 

The  X-ray  gives  valuable  information,  especially  after  the 
ureters  have  been  injected.  The  urine  rarely  shows  any  particular 
modification,  except  those  due  to  slight  hyperemia  after  Dietl's 
crisis. 


262  THE  KIDNEYS 

The  symptoms  may  be  either  local  or  general.  Vague  nervous 
states  are  usually  present.  These  are  very  much  the  same  as  those 
found  in  other  constant  nervous  irritations.  Dietl's  crises  or  "incar- 
ceration symptoms"  are  attacks  of  severe  pain,  sometimes  with 
symptoms  of  collapse,  which  occur  in  floating  kidney  and  were  at 
first  supposed  to  be  due  to  the  incarceration  of  the  organ.  It  now 
seems  certain,  however,  that  the  symptoms  are  due  to  the  torsion 
of  the  ureter  or  of  the  renal  vessels. 

Treatment.  The  general  treatment  for  visceroptosis  should  be 
instituted.  Tight  lacing  and  other  faulty  habits  of  dress  must  be 
corrected.  The  kidney  should  be  pushed  back  into  its  normal 
position  and  held  there  by  properly  fitted  bandages  or  corsets. 
The  correction  of  lesions  affecting  the  lower  thoracic  spinal  column 
and  the  lower  ribs  is  an  important  factor  in  securing  better 
tone  of  the  abdominal  muscles  and  of  the  supporting  tissues  of  the 
abdominal  organs.  The  patient  must  be  guarded  against  heavy 
lifting,  running  upstairs,  straining  at  stool,  or  any  violent  muscular 
effort.  A  full  diet  in  order  that  the  patient  may  gain  in  weight  is 
frequently  beneficial. 

Attempted  surgical  relief  of  the  condition  is  much  less  common 
now  than  it  was  a  few  years  ago.  In  some  cases  the  kidney  may 
be  attached  to  the  abdominal  wall  with  benefit,  but  this  should  not 
be  advised  until  milder  measures  have  failed. 


NEOPLASMS  OF  THE  KIDNEY 

The  kidney  is  subject  to  both  benign  and  malignant  tumor 
'growths.  The  adenoma  may  be  single  or  multiple  and  usually 
undergoes  cystic  degeneration.  Lymphadenoma,  angioma,  fibroma 
and  lipoma  may  occur  and  may  produce  little  or  no  symptoms 
until  the  tumor  has  reached  considerable  size. 

Sarcoma  is  sometimes  found  in  children.  It  may  be  associated 
with  rhabdomyoma.  Carcinoma  is  somewhat  less  rare  as  a  pri- 
mary condition.  Renal  carcinoma  is  somewhat  common  as  metas- 
tasis. The  hypernephroma  is  a  tumor  of  the  kidney,  due  to  the 
presence  of  an  overgrowth  within  the  kidney  of  masses  of  tissue, 
resembling  aberrant  suprarenal  masses.  These  are  frequently  cap- 
sulated  and  resemble  benign  growths,  but  their  rapidity,  metas- 
tases, and  peculiar  secretory  activity  causes  them  to  be  somewhat 
more  properly  included  among  the  malignant  neoplasms  of  the 
body. 

Diagnosis.  Dull  pain  in  the  loins  is  usually  present.  The  tumor 
cannot  be  recognized  by  palpation  until  it  reaches  considerable 
size.  The  X-ray  is  often  helpful  in  diagnosis.  Hematuria,  casts, 
cells  from  the  tumor,  may  be  present  in  the  urine.     The  occur- 


CYSTS  263 

rence  of  cancerous  cachexia  with  the  symptoms  above  mentioned 
may  make  the  diagnosis  fairly  certain. 

Treatment.  The  surgical  removal  of  the  entire  kidney  while 
the  growth  is  very  small,  should  leave  the  patient  in  good  con^ 
dition.  Unfortunately  the  diagnosis  is  not  usually  made  until  the 
tumor  has  reached  so  great  a  size  and  has  given  rise  to  such  wide 
nietastases  that  there  is  no  possibility  of  relief.  Children  die  some- 
what more  speedily  than  adults.  Death  usually  occurs  in  a  few 
weeks  to  a  year  after  the  appearance  of  the  first  symptoms. 

CYSTIC  KIDNEY     - 

(Renal  cyst) 

Renal  cysts  are  congenital  and  multiple.  Rarely  cysts  may 
appear  in  the  kidneys  during  later  life,  as  the  result  of  degenera- 
tion processes  occurring  in  the  kidney  parenchyma.  Renal  adenoma 
may  become  cystic. 

Diagnosis.  The  symptoms  are  somewhat  like  those  of  chronic 
interstitial  nephritis.  The  diagnosis  is  extrefnely  difficult  and  is 
frequently  made  only  post-mortem. 

When  there  is  reason  to  suppose  that  only  one  kidney  is 
involved,  or  the  cyst  is  solitary,  surgical  treatment  may  give  a 
reasonably  favorable  outlook.  If  both  kidneys  are  involved,  the 
condition  is  invariably  rapidly  fatal,  after  the  appearance  of  the 
first  symptoms. 

EMBOLISM  OF  THE  KIDNEY 

After  leaving  the  renal  arcades  the  renal  arteries  are  terminal. 
Emboli  reaching  these  produce  small  connected  infarction  areas. 
These  are  rarely  diagnosed  ante-mortem,  but  may  be  suspected 
when  patients  with  endocarditis,  or  any  other  recognizable  source 
of  emboli,  suffer  from  a  sudden  pain  over  the  kidney  with  tender- 
ness in  that  region  and  the  sudden  appearance  of  blood  in  the  urine. 

Rest  and  palliative  measures  are  the  only  treatment  required. 
The  infarct  area  usually  becomes  filled  with  connective  tissue  and 
if  this  accident  occurs  several  times  the  kidney  is  irregularly 
shrunken  and  presents  a  mottled  appearance  on  section. 


CHAPTER  XXVI 
DISEASES  OF  THE  BLADDER 

THE  NEUROSES  OF  THE  BLADDER 

The  nervous  control  of  the  bladder  is  partly  reflex  and  is  some- 
what directly  voluntary.  The  lumbar  segments  of  the  spinal  cord 
receive  sensory  impulses,  from  the  bladder  and  the  urethra  as  well 
as  from  the  skin,  muscles,  articular  surfaces,  and  other  pelvic 
viscera.  Descending  impulses  from  the  cerebral  cortex  and  the 
lower  brain  centers  act  upon  the  micturition  center  in  the  lumbar 
cord,  and  thus  the  voluntary  control  of  the  bladder  is  secured. 

Conditions  which  interfere  with  the  normal  activity  of  any  of 
these  nerve  centers  are  included  in  the  term  neuroses  of  the  blad- 
der. It  is  a  very  common  occurrence  for  involuntary  micturition 
to  occur  under  the  influence  of  intense  emotional  excitement.  In 
neurasthenic  individuals  and  in  some  functional  insanities  the 
muscular  tone  of  the  bladder  is  deficient,  probably  as  the  result 
of  the  asthenic  state  of  the  nerve  centers  in  the  lumbar  cord,  and 
the  bladder  is  permitted  to  remain  unemptied  for  considerable 
time — in  some  cases  as  much  as  a  gallon  of  urine  has  been  thus 
retained.  In  this  atonic  form  the  bladder  does  not  become  rup- 
tured unless  there  is  associated  with  the  neurosis  some  local  disease. 

More  commonly  the  inhibitors  of  the  micturition  center  are 
asthenic  and  the  bladder  becomes  unduly  irritable.  This  is 
almost  invariably  the  case  in  hysteria,  and  is  present  in  most  indi- 
viduals to  a  slight  extent  when  they  are  affected  by  fatigue  or 
long-continued  emotional  strain.  Under  such  circumstances  mic- 
turition occurs  at  short  intervals,  with  the  voiding  of  very  small 
quantities  of  urine.  The  treatment  of  this  condition  is  that  of 
the  underlying  neurosis. 

Local  sensory  disturbances  act  upon  the  micturition  center 
also.  Disturbed  bladder  control  is  usually  present  in  women  who 
suffer  from  disease  of  the  vagina,  uterus,  and  more  rarely  of  the 
ovaries  or  tubes.  Sometimes  this  lack  of  control  may  be  due  to 
mechanical  pressure,  as  by  tumors  or  malpositions,  rather  than 
as  the  result  of  a  lack  of  nervous  control.  In  men  the  irritation 
arising  from  disease  of  the  prostate,  urethra,  and  more  rarely  the 
scrotum  affect  the  nervous  control  of  the  bladder.  This  is  more 
apt  to  occur  in  men  who  are  of  neurotic  temperament. 

Bony  lesions  include  most  commonly  lumbo-sacral  and  sacro- 
iliac subluxations.  Less  frequently  lesions  of  the  coccyx  and  of 
the  upper  lumbar  vertebrae  are  concerned  in  disturbed  control  of 

264 


ENURESIS  265 

the  bladder.  -The  bladder  disturbances  which  result  from  organic 
nervous  diseases  are  considered  with  these  diseases. 

ENURESIS 

(Bed  wetting) 

The  reflex  nerve  control  of  the  bladder  is  completed  at  birth. 
In  a  baby  the  filling  of  the  bladder  initiates  the  nervous  mechan- 
ism which  empties  it.  The  process  is  entirely  involuntary,  and 
so  far  as  can  be  determined,  unconscious.  During  the  second  year 
of  life  the  spinal  nerve  tracts  to  and  from  the  brain  become 
developed  and  functional.  At  this  time,  it  is  best  for  a  child  to  be 
taught  to  exercise  voluntary  control  over  the  act  of  micturition.  It 
is  not  necessary  that  he  should  be  taught  to  exercise  this  control, 
since  he  will  grow  naturally  into  the  habit  of  consulting  his  com- 
fort and  convenience,  but  a  certain  amount  of  education  leads  to 
somewhat  earlier  and  certainly  more  efficient  bladder  control. 
Efforts  toward  establishing  the  volitional  control  before  the  neces- 
sary nerve  connections  are  made,  are  useless.  The  whole  process 
may  be  greatly  delayed  by  ill-judged  attempts  at  education,  espe- 
cially when  this  takes  the  form  of  whipping,  or  of  punishment 
which  unduly  excites  the  whole  nervous  system,  especially  in  neu- 
rotic children. 

A  child  which  is  only  a  few  months  old  has  regular  habits,  if 
it  has  been  well  cared  for,  and  with  a  little  attention  on  the  part 
of  the  nurse,  the  bladder  may  be  emptied  without  soiling  the 
clothing,  but  a  child  under  one  year  is  rarely  able  to  delay  mictu- 
rition voluntarily. 

When  bed  wetting  or  involuntary  micturition  during  the  day- 
time persists  beyond  the  second  year  of  life,  the  condition  of  the 
child's  health  must  be  investigated.  Any  of  the  functional  nervous 
diseases  may  be  responsible  for  this  condition.  Nocturnal  epilepsy 
and  petit  mal  must  not  be  forgotten  in  the  search  for  causes.  Local 
conditions  sometimes  require  careful  study.  Innominate  and 
lumbo-sacral  lesions  are  much  more  common  among  children  than 
is  generally  recognized.  The  correction  of  these  lesions  may  be 
all  that  is  necessary  for  immediate  recovery.  The  possibility  of 
anemia  and  malnutrition  should  be  investigated.  In  either  sex  un- 
cleanliness,  rectal  irritation,  vesical  calculi,  highly  acid  and  con- 
centrated urine,  worms,  tight  clothing,  masturbation  and  bad  train- 
ing are  etiological  factors  which  have  only  to  be  recognized  in 
order  to  receive  suitable  curative  measures. 

The  child  who  suffers  from  bed  wetting  should  not  be  permitted 
to  drink  much  water  during  the  evening  hours,  nor  to  eat  his 
heartiest  meal  at  night.  After  he  has  been  in  bed  an  hour  or  two, 
he  should  be  awakened  and  induced  to  empty  the  bladder.  The 
habit  will  soon  become  fixed.    Care  should  be  taken  that  the  night 


266  THE  BLADDER 

clothing  fits  properly.     A  firm  and  plain  talk  with  the  child  old 
enough  to  understand  conditions,  is  much  better  than  scolding  or 
punishments. 
The  prognosis  is  good  in  all  cases,  except  those  due  to  epilepsy. 


ACUTE  CYSTITIS 

Inflammation  of  the  urinary  bladder  occurs  at  almost  any  time 
of  life,  but  its  etiology  varies  at  different  periods  of  life.  A  pre- 
disposing cause  of  cystitis  is  found  in  lesions  of  the  lumbar  ver- 
tebrae, the  sacrum,  innominates  and  coccyx.  These  act  by  dis- 
turbing the  nervous  control  of  the  blood  vessels  of  the  bladder,  and 
also  by  interfering  with  the  reflex  mechanism  which  controls  its 
emptying. 

The  milder  forms  of  catarrhal  cystitis  are  associated  with  red- 
ness, swelling  and  epithelial  exfoliations  of  the  mucous  membrane 
lining  the  bladder.  In  children  the  condition  is  most  frequently 
due  to  chilling,  caused  by  sitting  in  cold,  wet  places.  It  may 
result  from  injury,  as  by  falls  or  by  the  improper  use  of  a  catheter, 
or  by  the  pressure  of  fetus  in  parturition.  More  commonly  catarrhal 
cystitis  is  due  to  the  influence  of  irritating  substances  in  the  urine, 
or  the  retention  of  the  urine  until  irritating  substances  have  been 
produced  by  fermentation.  Gouty  urine  is  usually  irritating.  Alco- 
hol and  drugs  frequently  cause  cystitis. 

Several  infectious  agents  may  set  up  a  cystitis,  which  varies  in 
severity.  During  the  progress  of  any  of  the  infectious  diseases, 
the  bladder  may  become  infected.  Gonorrhea  usually  reaches  the 
bladder  by  extension  from  the  urethra.  Various  forms  of  yeast 
and  mold  infection  of  the  bladder  have  been  described.  Infection 
by  means  of  the  pyogenic  organisms  may  result  in  the  formation 
■  of  small  abscesses  or  ulcers  in  the  wall  of  the  bladder.  Diseases 
of  the  pelvic  organs  may  affect  the  bladder  by  extension. 

In  all  cases  of  cystitis  the  symptoms  include  pain,  which  is 
usually  just  above  the  symphysis  pubis  and  which  often  extends 
around  to  the  back  over  the  lumbo-sacral  articulation,  down  into 
the  external  genitals  and  into  the  thighs.  Reflex  muscular  con- 
tractions across  the  lumbar  and  sacral  regions  and  involving  the 
abductors  of  the  thighs  are  commonly  present.  Micturition  usually 
occurs  at  very  short  intervals,  though  occasionally  the  bladder 
may  become  enormously  distended.  The  urinary  findings  include 
bladder  cells,  pus,  sometimes  blood,  sometimes  mucus,  and  some- 
times the  infectious  agent ;  this  should  give  the  diagnosis. 

Treatment.  The  treatment  should  include  the  relaxation  of  the 
reflex  muscular  contractions,  correction  of  lesions  as  found,  and 
such  movements  as  increase  the  mobility  of  the  lumbar  and  pelvic 
bones.     The  leg  movements  are  very  efficient  in  relieving  tension. 


CHRONIC  CYSTITIS  267 

The  local  treatment  depends  upon  the  underlying  cause  of  the 
cystitis.  Rest  and  warm  applications  are  beneficial.  In  all  cases 
a  constant  and  thorough  washing  of  the  bladder  with  a  warm,  non- 
irritating,  sterile  fluid  is  indicated.  This  is  best  secured  by  having 
the  fluid  flow  from  above  downward.  In  order  to  secure  this  con- 
stant irrigation  with  no  danger  of  sepsis,  it  is  best  to  use  the  urine 
itself,  by  having  the  patient  eat  little  or  no  food  and  drink  very 
freely  of  hot  and  cold  water.  In  order  to  make  the  water  more 
palatable,  fruit  juices  may  be  added,  but  no  alcohol  or  any  sub- 
stance which  could  possibly  irritate  the  kidneys  should  be  per- 
mitted. A  rigid  milk  diet  for  a  few  days  is  very  good,  if  it  is  pos- 
sible for  the  patient  to  take  the  milk  as  directed.  The  only  essential 
feature  is  providing  a  great  quantity  of  bland  urine. 

The  gonococcus  and  probably  the  yeast  and  mold  infections 
first  invade  the  superficial  epithelium.  As  this  is  constantly  being 
pushed  off  by  the  growth  of  the  cells  from  the  deeper  layers,  it  is 
evident  that  to  a  certain  extent  these  infections  are  self-limited, 
providing  the  bladder  epithelium  reproduces  itself  with  sufficient 
rapidity  and  the  exfoliated  cells  are  carried  away  as  rapidly  as 
possible  by  nonirritating  irrigation. 

"The  prognosis  in  acute  cystitis  is  good,  but  when  the  condition  is  chronic, 
it  is  less  favorable;  it  is  not  unfavorable,  however,  under  proper  treatment. 
When  it  is  due  to  tuberculosis,  enlargement  of  the  prostate,  or  is  associated 
with  disease  of  the  kidney,  its  recurrence  is  almost  certain.     .     .     . 

"Where  there  is  profuse  suppuration  with  rapid  decomposition,  the  bladder 
should  be  washed  out  at  least  twice  daily.  Where  the  cystitis  is  slight  in  grade, 
and  the  urine  is  not  decomposed,  irrigations  may  be  used  every  two  or  three 
days.  A  negative  microscopical  examination  is  the  only  proof  that  a  cure  has 
been  effected,  when  after  frequent  examinations  and  over  a  long  period  of  time 
it  remains  so." — P.  F.  Kani. 

CHRONIC  CYSTITIS 

The  mucous  membrane  in  chronic  cystitis  is  less  swollen  and 
is  usually  of  a  peculiar  bluish  color.  Erosions,  polypoid  growths 
and  thickenings  of  the  connective  tissue  of  the  bladder  wall  are 
characteristic.  Occasionally  these  pathological  changes  may  par- 
tially or  completely  obstruct  the  ureteral  passage,  and  the  urine 
thus  dammed  back  into  the  ureters  and  the  pelvis  of  the  kidney 
on  the  affected  side.  The  pain  is  less  severe  in  chronic  cystitis 
than  in  acute,  and  occasionally  is  referred  to  other  parts  of  the 
body.  Backache,  which  may  suggest  lumbago,  is  usually  asso- 
ciated with  contractions  of  certain  muscle  groups  of  the  lumbo- 
sacral neighborhood  and  with  a  loss  of  tone  of  other  muscle  groups. 
Examination  of  the  urine  shows  varying  amounts  of  pus,  mucin, 
blood,  bacteria,  and  albumin.  The  kidney  may  be  affected,  also, 
in  which  case  renal  epithelium  and  true  casts  are  present.  Also, 
the  examination  of  the  catheterized  specimen  should  show  the 
nature  of  the  infectious  agent. 


268  THE  BLADDER 

The  etiology  and  treatment  of  chronic  cystitis  are  the  same 
as  that  of  acute  cystitis.  The  prognosis  is  someVv^hat  less  favorable 
but  if  uncomplicated,  recovery  should  occur,  provided  the  patient 
is  reasonably  obedient  to  instructions  given  him. 

Neoplasms  of  the  Bladder.  Primary  tumors  of  the  bladder  or  rarely 
tumors  of  other  pelvic  viscera  may  extend  to  and  invade  the  bladder.  These 
cause  varying  degrees  of  cystitis  and  other  symptoms,  according  to  whether  the 
wall  of  the  bladder  is,  or  is  not,  penetrated. 

The  diagnosis,  treatment,  and  prognosis  of  vesical  neoplasms  is  that  of  the 
origin  of  the  tumor. 

Vesical  Hemorrhages.  Hemorrhage  of  the  bladder  occurs  as  the  result 
of  a  number  of  very  different  conditions.  Late  in  pregnancy,  it  may  be  due  to 
hemorrhage  per  diapedesin  or  hemorrhage  per  rhexin.  Dilatation  of  the 
veins  may  result  in  the  formation  of  vesical  hemorrhoids,  and  these  are 
very  liable  to  rupture.  Vesical  calculi  may  so  injure  the  wall  of  the  bladder 
as  to  produce  severe  hemorrhages.  Any  of  the  causes  of  cystitis  may  be  so 
serious  as  to  cause  rupture  of  the  blood  vessel  or  capillary  hemorrhages. 

The  diagnosis  rests  upon  finding  the  blood  in  the  urine,  the  recognition  of 
the  underlying  causes  and  upon  the  cystoscopic  examination.  The  X-ray  should 
show  the  presence  of  calculi.  After  filling  the  bladder  with  a  coUargol  solution, 
any  marked  irregularities  of  the  bladder  wall  become  evident. 

DISEASES  OF  THE  URETHRA 

Diseases  of  the  urethra  are  usually  surgical  and  are  discussed 
in  text-books  of  genito-urinary  diseases.  Specific  infections  and 
the  adhesions  of  connective  tissues,  and  overgrowths  which  result 
from  earlier  inflammation  are  the  most  important  causes  of  urethral 
diseases.  Direct  injury  is  not  rare.  Disease  of  the  urethra  is 
usually  associated  with  severe  local  pain  and  reflex  muscular  con- 
tractions over  the  sacrum.  Recovery  from  these  conditions,  either 
without  surgery,  or  after  the  necessary  surgical  operations  have 
been  performed,  is  made  more  speedy  and  complete  if  these  reflex 
muscular  contractions  and  any  bony  lesions  that  may  be  found 
upon  examination  receive  suitable  attention. 

DISEASES  OF  THE  PROSTATE 

Acute  prostatitis  is  usually  due  to  infection  by  the  gonococcus,  tubercle 
bacillus,  staphylococcus,  bacillus  coli,  or  other  bacteria.  Lesions  of  the  sacrum, 
innominates  or  coccyx,  or  of  the  lumbar  vertebrae  are  predisposing  factors. 
The  symptoms  include  pain  on  sitting,  defecation  or  urination,  vesical  and 
rectal  tenesmus  and  hematuria.  Abscess  may  result,  which  may  drain  without 
much  evil  after-effects,  or  may  break  into  the  rectum,  bladder,  or  neighboring 
tissues. 

Chronic  prostatitis  may  result  from  repeated  attacks  of  the  acute  form, 
or  from  the  constant  action  of  the  etiological  factors.  The  symptoms  include 
referred  pains  in  rectum,  perineum,  back,  legs,  and  upward  toward  the  kidneys, 
melancholy  and  neurasthenic  states,  circulatory  disturbances,  and  various  dis- 
turbances of  sexual  functions.  Chronic  rheumatism  and  endocarditis  are  prob- 
ably often  due  to  chronic  prostatitis. 

Hypertrophy  of  the  prostate  is  common  in  elderly  men.  Infections,  con- 
stipation,  bony  lesions  of  the  pelvic  girdle,   and  circulatory   disturbances  are 


URETHRA  AND  PROSTATE  269 

etiological   factors.     The  symptoms   include  those   of  chronic   prostatitis,   and 
careful  examination  gives  evidence  of  the  enlarged  prostate.     Care   must  be 
taken    to    avoid    confusing    chronic    prostatitis,    hypertrophy    and    prostatic- 
neoplasms. 

Neoplasms  of  the  prostate.  Carcinoma  may  be  primary.  It  occurs  in 
men  over  fifty  years  old,  most  often  after  the  age  of  sixty  years.  Pain  is 
more  common  in  carcinoma  than  in  hypertrophy,  and  blood  is  more  often  found 
in  the  urine.  The  mass  is  found  to  be  larger  upon  one  side  than  the  other ;  is 
distinctly  lobulated,  and  of  stony  hardness,  all  of  which  help  to  distinguish  it 
from  hypertrophy.  Sarcoma  is  softer  than  carcinoma,  and  is  less  distinctly 
lobulated.  Obstinate  sciatica  in  men  past  the  half-century  age  should  suggest 
the  disease.  Metastatic  growths  may  be  found  in  the  bones,  by  the  X-ray, 
sometimes  very  early  in  the  disease. 

Treatment.  In  all  these  cases  the  treatment  must  be  decided  after  exam- 
ination of  each  patient.  Surgical  interference  is  often  of  doubtful  value,  yet 
is  necessary  at  times.  Catheterization,  dilatation,  and  irrigation  must  be  per- 
formed, when  necessary,  under  the  most  aseptic  precautions  possible. 

Correction  of  the  bony  lesions  is  an  important  factor  in  the  treatment  of 
all  cases ;  in  certain  cases  this  is  all  that  is  necessary  to  secure  recovery.  In 
nearly  all  cases  careful  but  thorough  massage  every  week  or  ten  days  per 
rectum  of  the  contiguous  tissues  and  to  a  certain  extent  of  the  gland  itself  is 
beneficial. 

Examination  of  the  prostate  should  be'  a  routine  procedure  in  the  exam- 
ination of  men  whenever  the  diagnosis  is  uncertain,  especially  when  chronic 
rheumatism,  nervous  or  toxic  states  of  unknown  cause,  or  pain  in  the  region 
supplied  by  the  lumbar  and  sacral  nerves  are  included  in  the  symptoms. 


PART  VI 
THE  TOXIC  AND  CONSTITUTIONAL  DISEASES 


CHAPTER  XXVII 
GOUT  AND  RHEUMATISM 

GENERAL  DISCUSSION 

Recent  studies  have  thrown  the  old  names,  always  unsatisfac- 
tory, into  still  greater  confusion.  The  muscles  and  joints  are 
subject  to  the  adverse  influence  of  several  different  factors,  which 
may  act  singly  or  in  various  combinations  in  any  given  case. 

The  terms  "gout"  and  "gouty"  should  be  limited  to  those 
states  in  which  the  presence  of  excessive  amounts  of  uric  acid 
(monosodium  urate)  is  an  important  factor  in  pathogenesis. 

The  term  "rheumatism"  or  "rheumatic"  should  be  limited  to 
those  states  in  which  the  streptococcus  rheumaticus,  or  other  infec- 
tious agents,  or  bacterial  or  other  toxins,  are  responsible  for  the 
symptoms.  Septic  foci,  tonsillitis,  pyorrhea  alveolaris,  with  their 
secondary  infections,  gonorrhea,  latent  infections  anywhere  in  the 
body,  are  to  be  considered  in  these  diseases. 

There  are  other  muscular  and  arthritic  states  in  which  the  senile 
connective  tissue  hardening  seems  to  be  the  only  causative  agent; 
others  in  which  nervous  disturbances  alone  appear  responsible; 
while  in  another  large  group  of  cases  the  cause  seems  to  be  the 
bony  lesion,  affecting  the  joint  either  directly,  or  indirectly 
through  its  nerve  or  blood  supply.  This  appears  to  be  the  case 
in  lumbago,  pleurodynia  and  cephalodynia,  especially,  (q.  v.) 

GOUT 

(Podagra,  gout  of  the  foot;  chiragra,  gout  of  the  hand;  gonagra,  gout  of  the 

knee) 

Gout  is  a  nutritional  disorder  of  unknown  pathogenesis,  asso- 
ciated with  an  excess  of  uric  acid  (monosodium  urate)  in  the  blood 
and  tissues,  and  manifested  clinically  by  periodic  attacks  of  acute 
arthritis,  usually  of  the  metatarso-phalangeal  joint  of  the  right 
great  toe,  certain  visceral  disturbances,  and  deformity  of  the  joints 
attacked. 

.    Etiology.    Heredity  is  a  considerable  factor.    It  develops  in  the 
grandchildren,  usually  the  males,  and  occurs  chiefly  in  middle  or 

270  '     , 


TYPES  271 

later  life.  Habitual  indulgence  in  heavy  or  sweet  wines  and  heavy- 
malt  liquors,  excessive  eating,  particularly  of  nitrogenous  food, 
with  sedentary  habits,  are  the  common  causes ;  defective  hygiene, 
and  sometimes  deficient  food,  may  cause  "poor  man's  gout." 

Chronic  lead  poisoning  is  often  accompanied  by  gouty  symp- 
toms. In  the  predisposed,  worry,  emotion,  or  a  trivial  injury  may 
determine  an  attack.  Disturbances  of  protein  metabolism,  not  yet 
understood,  interfere  with  the  purin  balance,  cause  increased  uric 
acid  in  the  blood  and  other  factors  which  produce  the  symptoms. 
Subluxation  of  the  bones  of  the  foot,  notably  the  astragalus,  or 
of  the  bones  of  any  other  part  affected,  together  with  subluxations 
in  the  spinal  area  from  which  the  nerve  supply  comes,  are  factors 
in  etiology. 

The  pathogenesis  is  uncertain.  Uric  acid  is  found  in  excess  in  the  blood, 
in  the  gouty  joint,  and  in  the  exuded  serum  of  gouty  arthritis. 

The  morbid  changes  are  outlined  as  follows  (taking  the  great  toe  as  a 
type)  :  Fine  crystalline  needles  are  deposited  in  the  interstitial  parts  of  the 
cartilage  and  in  the  synovial  fluid.  The  synovial  membrane,  cartilages,  and 
ligaments  become  covered  with  a  chalk-like  deposit  of  urates.  The  tissues 
underneath  are  more  or  less  necrosed. 

The  cartilages  may  be  eroded  and  the  synovial  membranes  thickened,  ends 
of  the  bones  are  enlarged  and  the  joints  deformed.  Nodular  masses  appear 
around  the  joints  consisting  of  urates  plus  calcium  phosphate — the  chalk- 
stones  or  tophi  of  gout.  These  may  ulcerate  through  the  skin.  They  appear  in 
other  structures  than  joints,  as  the  lobes  of  the  ears,  tendinous  aponeurosis  of 
muscles,  and  in  many  other  places. 

Several  types  of  gout  are  recognized,  according  to  the  effects 
produced  by  what  seems  to  be  a  common  metabolic  disturbance. 

Acute  gout  may  occur  as  a  single  attack,  or  may  recur  at  inter- 
vals, varying  with  the  habits  of  the  individual,  precipitated  by 
overindulgence  in  any  of  the  dietetic  errors  mentioned  in  etiology, 
by  emotional  storms  or  trauma.  Acute  attacks  occur  during  the 
course  of  chronic  gout. 

There  are  usually  premonitory  symptoms  consisting  of  dizzi- 
ness, mental  depression,  flatulence,  irritability  of  temper,  and 
scanty,  high-colored  urine.  The  attack  most  commonly  commences 
after  midnight  with  severe  pain  in  the  big  toe,  usually  the  right, 
the  pain  increasing  to  acute  agony.  The  patient  may  or  may  not 
become  feverish,  to  102°  F.  The  joint  is  first  a  bright  red  and 
exquisitely  painful ;  later  is  swollen,  of  a  dusky  red  color,  and  with 
distended  venules.  The  swelling  extends  for  some  distance  from 
the  joint.  Sudden  spasmodic  muscular  contractions  increase  the 
agony.  Toward  morning  the  symptoms  subside.  This  may  be 
repeated  several  times.  During  the  attack,  the  patient  is  usually 
most  irritable;  the  tongue  is  furred,  the  breath  offensive,  and  the 
bowels  constipated.  An  attack  lasts  from  five  to  eight  days,  the 
severity  of  the  symptoms  gradually  abating. 


272  GOUT 

The  skin  of  the  joint  desquamates  in  thick  flakes  after  the 
attack.  Subsequent  attacks  may  affect  the  joint  first  implicated, 
or  a  number  of  joints  may  become  involved.  If  the  attacks  are 
fairly  frequent,  they  cause  the  so-called  chronic  gout. 

Chronic  Gout  (gouty  arthritis).  The  small  joints  of  the  toes 
and  fingers  are  affected.  The  fingers  are  stiff,  swollen,  flexed,  or 
extended,  vSometimes  deflected  toward  the  ulnar  side.  Tophi  may 
form  in  the  joints,  the  bursae  or  in  the  cartilages  of  the  ears.  Con- 
stitutional symptoms  are  present  but  milder  than  in  the  acute 
form.    The  kidneys  are  affected. 

Suppressed  or  Retrocedent  Gout  is  a  condition  in  which  the 
development  of  internal  symptoms  coincides  with  rapid  disappear- 
ance of  the  joint  signs. 

The  symptoms  may  be  either  gastro-intestinal,  -with  nausea 
and  vomiting,  much  severe  pain,  usually  diarrhea  and  great,  even 
fatal,  prostration;  pulmonary,  as  asthma,  dyspnea;  cardiac,  with 
dyspnea,  pain,  arrhythmia,  pericarditis,  syncope ;  or  cerebral,  as 
headache  and  delirium  which  are  probably  uremic.  Any  of  the 
smaller  joints  may  become  affected.  Later,  renal  complications 
include  deposits  of  urates,  and  interstitial  nephritis.  Arteriosclero- 
sis is  a  common  accompaniment.  Uremia,  pleurisy,  pericarditis, 
peritonitis,  and  meningitis  are  common  terminal  affections. 

Irregular  Gout.  (Lithiasis;  uric  acid  diathesis;  lithemia;  lithe- 
mic  state;  uricemia;  American  gout.)  Lithemia  is  a  condition 
in  which  the  fluids  of  the  body  contain  an  excess  of  nitrogenized 
waste's  in  the  form  of  uric  acid  or  related  compounds,  occurring  in 
persons  not  suffering  from  articular  gout  and  manifested  by 
various  digestive,  nervous,  and  circulatory  phenomena,  muscular 
and  articular  pains,  and  scanty,  high-colored  urine. 

The  symptoms  referred  to  the  digestive  system  include  esoph- 
ageal spasm,  gastralgia  or  gastritis ;  colic  or  enteritis ;  hepatic  dis- 
eases or  "bilious"  attacks  with  furred  tongue,  foul  breath,  consti- 
pated bowels,  and  torpid  liver.  Circulatory  phenomena  are 
palpitation,  arrhythmia,  cardialgia  or  angina  pectoris,  dyspnea, 
syncope.  The  blood  pressure  is  high,  the  vessel  walls  are  stiff,  and 
renal  changes  are  found.  Respiratory  symptoms  resemble  bron- 
chitis or  asthma.  Nervous  phenomena  are  varied  and  include 
headache,  neuritis,  neuralgia,  meningitis,  and  symptoms  of  cerebral 
congestion.  Skin  affections  as  eczema,  urticaria,  erythema  multi- 
forme, etc.,  may  occur.  Iritis,  glaucoma,  retinitis,  and  suppurative 
panopthalmitis  have  occurred.  Urinary  disturbances  include  gouty 
glycosuria,  oxaluria,  calculi  and  urethritis. 

The  complications  are  chronic  interstitial  nephritis,  chronic 
bronchitis,  hepatic  enlargement,  arteriosclerosis,  leading  to  apo- 
plexy, cardiac  hypertrophy  leading  to  dilatation. 


TRBATMBNT  .  273 

All  forms  of  gout  are  characterized  by  certain  common  factors. 
The  blood  pressure  is  always  increased.  The  blood  shows  no  com- 
mon factors,  but  there  is  usually  slight  leucocytosis.  The  granular 
leucocytes  show  the  effects  of  some  destructive  influence,  in  frag- 
mented nuclei,  vacuolated  protoplasm,  atypical  staining  reactions, 
and  ragged  cellular  outlines. 

The  urine  is  characteristic.  Before  and  during  an  acute  attack 
the  quantity  is  diminished;  color  high;  acid  reaction;  specific 
gravity  above  normal ;  urea  is  not  much  altered ;  uric  acid  is  dimin- 
ished during  the  paroxysm;  phosphates  are  nearly  always  dimin- 
ished ;  albumin  is  present  in  a  very  small  amount.  The  sediment 
contains  hyaline  and  granular  casts,  renal  cells  and  altered  blood 
cells  free  or  adherent  to  the  casts. 

Before  and  after  recovery  from  the  attack  the  quantity  is  nor*- 
mal  or  increased ;  the  normal  solids  are  usually  increased ;  uric 
acid  and  urates  are  greatly  increased,  while  evidence  of  more  or 
less  renal  irritation  persists. 

Treatment.  During  the  intervals  the  treatment  should  be 
devoted  to  securing  better  circulation  through  the  liver  especially ; 
to  the  removal  of  lesions  wherever  found;  to  securing  increased 
mobility  of  the  spinal  column ;  and  to  the  correction  of  hip,  innomi- 
nate and  lumbar  lesions  particularly.  Bony  lesions  of  the  foot  are 
frequent,  and  predispose  to  the  usual  location  in  the  toe. 

During  the  acute  stage  the  intense  pain  can  be  relieved  by 
careful  manipulation  of  the  joint  itself,  freeing  the  circulation 
around  it.  It  is  better  to  begin  at  the  hip,  working  down  to  the 
affected  joint.  The  joint  is  carefully  stretched  by  tension  and  a 
careful  side  to  side  motion  if  in  the  great  toe.  Hot  fomentations 
may  be  used.    The  limb  should  be  at  rest  and  elevated. 

Restrict  diet  to  milk  and  barley  water  during  the  attack  and 
make  the  patient  use  plenty  of  water.  The  mineral  waters  are 
of  no  special  use  except  for  the  water  content.  Lemon  juice  is  a 
very  good  addition  to  increase  the  quantity  of  water  taken. 

As  soon  as  the  patient  is  over  the  attack,  write  out  a  regulated 
diet  list  consisting  of  a  moderate  amount  of  nitrogenous  food 
without  excess  of  carbohydrates,  using  plenty  of  dairy  products, 
eggs,  fats,  green  vegetables,  fresh  fruits  except  strawberries  and 
bananas,  and  avoiding  foods  rich  in  nucleins,  tea,  coffee,  and 
alcohol.  Restrict  the  use  of  common  salt.  All  rich  foods  of  any 
kind  are  to  be  avoided.  Meals  must  be  regular.  Water  must  be 
freely  used,  preferably  between  meals.  Exercise  should  be  regular 
and  in  the  open  air,  walking  and  golf  are  advisable.  Rides  are 
good  if  walking  is  painful.  In  the  robust,  cold  baths  may  be 
taken  each  morning;  the  warm  evening  bath  is  more  beneficial 
'for  weaker  patients.  Friction  should  follow  the  bath.  The  cloth- 
ing must  be  warm.    Residence  in  a  warm  climate  is  often  advisable. 


274  RHEUMATISM 

After  the  acute  attack  subsides,  gentle  friction  and  passive 
movements  for  the  affected  joint  promote  recovery. 

Prognosis.  Acute  gout  is  rarely  fatal  but  is  prone  to  recur. 
Chronic  gout  has  a  less  favorable  outlook,  as  the  renal,  arterial, 
and  cardiac  complications  shorten  life.  Acute  diseases  and  injuries 
arising  during  its  course  are  more  serious  than  under  other  cir- 
cumstances.    Suppressed  gout  may  be  fatal  at  any  time. 

MUSCULAR  RHEUMATISM 

(Myalgia,  myositis,  fibrositis) 

Muscular  rheumatism  is  an  inflammatory  affection  of  the  vol- 
untary muscles  and  their  fibrous  attachments,  marked  by  pain, 
tenderness,  and  stiffness  of  the  affected  muscle. 

Etiology.  Muscular  overstrain  and  exposure  to  cold  and  damp, 
bony  lesions  affecting  the  yaso-motor  or  sensory  nerve  centers  of 
the  muscles  affected,  gout,  septic  foci  anywhere  in  the  body,  and 
rarely  extension  from  a  chronic  infection  of  neighboring  joints, 
are  the  usual  cases  found. 

Diagnosis.  The  general  symptoms  are:  a  rather  sudden  onset 
with  pain,  slight  tenderness,  and  stiffness  of  the  affected  muscles, 
increased  on  any  attempt  at  movement.  Spasmodic  contraction 
and  rigidity  of  the  muscles  may  be  present.  Fever  and  constitu- 
tional symptoms  are  absent.  The  variety  depends  upon  the  loca- 
tion. 

Lumbago.  (Lumbodynia.)  The  aponeurosis  of  the  erector 
spinse  and  the  latissimus  dorsi  is  most  frequently  affected.  Lumbar 
subluxations  are  usually  present.  It  is  often  attributed  to  some 
physical  exertion  such  as  heavy  lifting.  The  pain  usually  affects 
both  sides,  is  often  severe  and  may  affect  locomotion.  When  com- 
plicated with  sciatica,  the  suffering  is  intense. 

"Lumbago  is  usually  classed  among  the  myalgias,  but,  as  a  rule,  it  is  rather 
a  distortion  of  one  of  the  lateral  joints  of  the  spine,  due  to  sudden  movement 
when  the  joint  has  not  been  prepared  for  it  by  prehminary  fixation." — L.  F. 
Barker,  Johns  Hopkins. 

Cephalodynia  is  situated  in  the  occipito-frontal  muscles.  It  is 
distinguished  from  facial  or  occipital  neuralgia  by  pain  on  both 
sides  of  the  head  aggravated  by  movement.  It  may  affect  the 
eye  muscles  when  movement  of  the  eye-ball  excites  the  pain ; 
or  the  temporal  muscle,  rarely.  The  masseter  muscles  are  involved 
when  pain  is  induced  by  mastication.  The  trouble  can  be  often 
traced  to  the  upper  five  cervical  vertebrce. 

"  Muscular  Torticollis.  (Wry  or  stiff  neck.)  The  sterno-mastoid 
muscle  of  one  side  only  is  the  usual  one  affected  so  the  head  is 
twisted  and  great  pain  is  excited  on  attempting  to  turn  it.    This 


MUSCULAR  275 

form  must  not  be  confused  with  spasmodic  torticollis  nor  with 
congenital  deformity.  Subluxations  of  the  third,  fourth,  and  fifth 
cervical  vertebrae  are  usually  found.  If  the  muscles  of  the  back 
of  the  neck  are  involved,  it  is  known  as  cervicodynia. 

Pleurodynia.  The  sheaths  of  the  pectoral  muscles,  the  inter- 
costals,  or  the  serratus  magnus  are  most  commonly  affected. 
Respiratory  movement  of  the  affected  side  is  embarrassed ;  the 
patient  often  leaning  toward  that  side,  and  pain  is  excited  by 
forced  respiration,  coughing  or  sneezing.  It  may  be  mistaken  for 
pleurisy  but  the  concomitant  signs  are  absent  except  for  a  distinct 
fremitus.  The  subluxations  found  are  those  of  the  ribs  and  their 
corresponding  vertebrae. 

Treatment.  In  any  form  of  muscular  rheumatism  search  must 
be  made  for  some  source  of  poison  or  infection.  The  teeth,  tonsils, 
nose,  middle  ear,  gall-bladder,  intestines,  genito-urinary  tract, 
may  be  associated  with  septic  foci  which  constantly  give  either 
bacteria  or  toxins  to  the  blood.  These  must  be  properly  treated 
if  recovery  is  to  be  permanent. 

Fomentations  applied  to  the  aft'ected  area  for  twenty  minutes 
prior  to  treatment  is  of  considerable  assistance.  Careful,  forced 
flexion  of  the  thighs  on  abdomen  for  three  of  four  minutes  is 
frequently  effective  in  lumbago.  Springing  the  spine  from  the 
tenth  dorsal  to  the  fourth  lumbar,  gently,  may  permit  corrections 
to  be  made  with  greater  ease.  Applications  of  heat  may  be  needed 
to  prevent  muscular  tension  from  reproducing  the  lesion  after  cor- 
rection has  been  made.  Adhesive  straps  may  be  useful  in  main- 
taining the  normal  relations.  Thorough  careful  relaxation  of  the 
muscles  affected,  then  correction  of  the  specific  lesions  found  will 
often  relieve  the  patient  immediately  in  acute  cases.  Stimulation 
in  the  splanchnic  area  is  helpful  in  promoting  elimination.  In 
chronic  cases  more  time  is  required  as  the  subluxations  are  harder 
to  reduce. 

"In  torticollis,  lesions  may  be  found  from  the  first  to  the  seventh  cervical 
vertebrae,  and  first  and  second  dorsal.  A  lesion  of  the  first  and  second  ribs  may 
interfere  by  misplacement  or  pressure  with  the  blood  or  nerve  supply  to  the  neck. 
The  affected  muscles  undergo  fibrous  degeneration,  becoming  hard  and  unyield- 
ing. The  sternal  head  of  the  sterno-mastoid  muscle  is  more  frequently  affected 
symptomatically.  There  is  pain  on  motion  of  the  affected  muscle  and  it  becomes 
tense  and  stands  out  prominently  from  beneath  the  skin.  The  tenderness  is 
marked.    The  head  is  drawn  to  one  side  and  the  face  rotated  upward. 

"In  severe  cases  the  face  may  look  directly  toward  the  shoulder  of  the 
unaffected  side.  The  sterno-mastoid  muscle  originates  on  the  manubrium  and 
clavicle  and  is  directed  upward  and  backward  to  the  mastoid  process  and 
adjacent  portion  of  the  occipital  bone.  It  flexes  laterally  the  head  and  neck 
and  rotates  the  face  to  the  opposite  side  and  when  acting  conjointly  with  its 
fellow,  raises  the  manubrium  and  clavicle  or  flexes  the  head  or  neck.  The 
constant  pulling  of  the  muscle  would  cause  lesions  of  the  axis. 

"Cases  have  been  cured  osteopathically  after  section  of  the  muscle  and 
resection    of    the    nerve    have    failed.     The    treatment    consists    ia   correcting 


276  RHEUMATISM 

the  lesions  and  improving  the  general  health.    Where  the  lesion  is  the  primary 
cause,  correction  of  the  same  will  accomplish  a  cure." — G,  W.  Goode. 

"Take  a  case  of  torticollis  where  the  patient's  neck  is  too  stiff  and  sore  to 
manipulate,  and,  as  often  in  such  cases,  manipulation  aggravates  rather  than 
helps:  I  give  the  patient  just  enough  ether  or  chloroform  to  relax,  then,  with 
great  care  to  avoid  any  additional  irritation  to  the  joint,  gently  adjust  the  third 
and  fourth  cervical.  I  have  never  failed  to  find  a  lesion  there  and  I  have  never 
failed  to  produce  a  cure  in  one  treatment,  that  is  in  acute  cases." — C.  G.  Hewes. 

The  prognosis  is  favorable  for  recovery.  The  chronic  form  fre- 
quently recurs,  especially  with  changes  in  the  weather,  hence  the 
patient  must  increase  his  resistance  by  continued  treatment  for 
some  time,  by  correct  habits  of  living,  and  by  avoiding  things 
which  tend  to  produce  his  particular  subluxation. 


THE  CHRONIC  ARTHRITIDES 

(Including  chronic  articular  rheumatism;  rheumatoid  arthritis;  rheumatic  gout; 
hypertrophic  arthritis  or  osteo-arthritis ;  chronic  infectious 
arthropathy;  chronic  progressive  polyarthritis) 

These  diseases  are  thus  grouped  because  the  essential  nature 
of  all  is  now  more  or  less  uncertain,  and  because  they  have  so  many 
factors  in  common,  with  our  present  ignorance  of  their  patho- 
genesis. 

Etiology.  The  bacterial  origin  of  all  forms  of  rheumatism  must 
be  suspected.  Septic  foci  in  tonsils,  intestinal  tract,  generative 
organs,  middle  ear,  around  the  teeth,  and  other  locatiofls  may  be 
responsible  for  either  chronic  infection  or  chronic  poisoning. 
Poverty,  exposure,  especially  to  cold  and  wet ;  trauma ;  worry ; 
grief;  fear;  uterine  and  ovarian  disease,  heredity  of  tuberculosis, 
gout  or  rheumatism,  or  anything  which  lowers  the  general  vitality, 
predisposes  to  the  disease.  Subluxations  of  vertebrae  increase 
predisposition.  An  acute  form  appears  to  be  infectious.  Lesions 
aflFecting  the  innervation  of  the  involved  joints  are  constant — 
usually  this  includes  structural  impediments  affecting  the  nerve 
trunks,  as  well  as  vertebral  subluxations.  Lesions  of  the  first  rib 
and  clavicle,  with  contractions  of  the  scaleni,  may  exert  direct 
pressure  upon  the  brachial  plexus;  these  lesions  are  also  effective 
as  reflex  disturbances  affecting  the  trophic  centers  of  the  cervical 
enlargement.  Lesions  of  the  lumbo-sacral  region  are  associated 
with  tension  of  the  psoas  magnus ;  this  causes  slight  direct  pressure 
upon  the  lumbar  plexus;  this  also  exerts  a  reflex  effect  upon  the 
trophic  centers  in  the  lumbar  enlargement.  These  lesions  are 
constant,  in  trophic  affections  of  the  articulations  of  hands  and  feet.' 

Pathology.  In  arthritis  deformans  the  disease  begins  in  the  car- 
tilages and  synovial  membranes.  The  cartilages  become  soft  and  vascular 
and  are  gradually  absorbed;  the  result  is  the  approximation  of  the  two  articular 
surfaces  which  become  very  dense,  hard,  and  highly  polished — eburnation. 
Rarefaction  and  atrophy  may  occur,  leading  to  shortening  and  deformity.    The 


CHRONIC  ARTHRITIDES        .  277 

synovial  membranes  are  inflamed  and  thickened;  often  portions  become  de- 
tached and  form  loose  bodies  in  the  joint. 

Ligaments  are  thickened,  contracted,  sometimes  calcified.  Ankylosis  is 
rarely  complete.  At  the  margin  of  the  joint  where  pressure  is  less,  ossification 
goes  on,  resulting  in  the  formation  of  irregular  bony  outgrowths,  called  osteo- 
phytes. There  is  not  tendency  to  suppuration;  muscular  atrophy  is  a  common 
accompaniment. 

In  chronic  rheumatism  the  shoulder  and  the  knee  are  most  frequently 
affected.  The  fibrous  tissues  are  chiefly  involved;  the  synovial  membranes  may 
be  reddened  but  effusion  is  very  slight.  The  capsules  and  ligaments  of  the 
joints,  sheaths  of  adjacent  tendons,  and  aponeurotic  sheaths  of  muscles  may 
be  implicated.  These  become  thickened  and  inflamed,  thus  limiting  joint 
movement.     There  is  little  deformity  and  no  bony  ankylosis. 

Pain  and  stiffness  of  the  parts  involved  are  the  main  features.  This 
state  is  aggravated  by  damp  or  stormy  weather.  The  joints  may  be  a  little 
swollen  and  tenderness  present  during  the  acute  exacerbations.  Many  joints 
may  be  involved.  The  pain  is  usually  worse  at  night,  and  in  the  morning  it 
may  be  very  severe,  but  after  exercise  it  mitigates  until  it  is  tolerable  but  does 
not  disappear.  The  joints  may  be  felt  and  heard  to  creak.  In  very  chronic 
cases,  some  atrophy  of  the  muscles  occurs;  permanent  stiffness  or  even  fibrous 
ankylosis  may  follow. 

Spondylitis  Deformans  is  the  name  given  when  the  disease 
attacks  the  vertebrae.  It  is  more  common  in  men.  The  spinal 
column  becomes  completely  rigid  and  strongly  kyphotic. 

Mono-articular  form  attacks  spine,  shoulder  or  hip,  in  elderly 
men. 

General  Progressive  Form.  The  process  affects  the  smaller 
joints  symmetrically,  especially  the  metacarpo-phalangeal  and 
inter-phalangeal  joints  of  the  hands.  At  first,  the  joints  may  be 
red,  swollen,  and  tender,  but  this  stage  may  not  appear.  Later,  or 
from  the  beginning  in  other  cases,  stiffness  and  gradual  deformity 
without  signs  of  inflammation  are  present.  The  joint  changes  and 
the  accompanying  muscular  atrophy  cause  the  deformities  to 
assume  a  very  characteristic  appearance.  The  lower  ends  of  the 
ulna  and  radius  project  at  the  wrist,  the  metacarpo-phalangeal 
joints  are  flexed,  the  first  phalangeal  joints  are  overextended,  the 
second  are  flexed,  and  the  fingers  deviate  to  the  ulnar  side.  The 
joints  give  forth  a  creaking  sound  when  moved.  The  attached 
muscles  are  subject  to  cramps.  The  temporo-mandibular  articula- 
tion is  apt  to  be  affected. 

The  pulse  is  rapid,  100  to  120,  or  even  higher,  soft  and  com- 
pressible in  the  presence  of  a  normal  temperature.  A  return  to  a 
normal  pulse-frequency  is  a  sign  that  the  process  of  the  disease  is 
arrested. 

The  skin  is  soft,  subject  to  local  sweats,  often  moist  and  clammy ; 
diffuse  melasmic  discolorations,  or  level  dark-brown  patches  with 
numbness  and  tingling,  are  often  present.  The  blood,  blood  pres- 
sure and  urine  show  no  characteristic  changes.  The  majority 
of  patients  reach  a  quiescent  stage,  suffer  no  pain  and  enjoy  ex- 
cellent health  except  for  the  inconvenience  due  to  deformity. 


278  RHEUMATISM 

The  osteophytes  upon  the  hands  receive  the  name  of  Heber- 
den's  or  Haygarth's  Nodosities.  They  occur  most  commonly  in 
middle-aged  women,  especially  those  who  have  long  suffered  diges- 
tive troubles.  Little  transparent  cysts,  possibly  pouches  of  syno- 
vial membranes,  may  be  associated  with  the  nodes.  After  the 
hands  and  wrists,  the  knees  and  ankles  may  become  involved. 
The  thumb  and  the  large  joints  usually  escape.  The  muscular 
atrophy  is  largely  contributed  to  by  nonuse. 

The  acute  form  is  much  less  common  than  the  chronic.  After 
a  febrile  onset,  the  joints  become  distended  with  fluid  and  are 
speedily  disorganized.  Erosion  of  the  cartilages  with  a  grating 
sound  on  motion  follows  but  there  are  no  osteophytes.  It  may 
subside  in  about  a  month  or  become  chronic. 

In  children,  it  follows  a  somewhat  different  course.  The  onset 
is  always  before  the  second  dentition  with  an  attack  which  may 
be  febrile,  slight  stiffness  of  one  or  two  joints,  gradually  extend- 
ing to  others.  There  is  no  bony  grating.  The  enlargement  is  due 
to  general  thickening  and  not  to  bony  overgrowth.  Limitation  of 
movement  may  be  extreme  and  there  may  be  muscular  wasting. 
There  is  enlargement  of  the  spleen  and  lymph  glands,  which  may 
be  general,  the  lymph  glands  being  quite  large.  Sweating  is  pro- 
fuse. There  is  anemia  although  the  heart  complications  are  rare. 
The  children  look  puny  and  generally  show  arrest  of  development. 

Treatment.  Correction  of  any  lesions,  especially  those  men- 
tioned in  etiology,  is  absolutely  necessary.  Local  treatment  to  the 
joint  involved  must  be  careful,  and  is  occasionally  best  omitted. 
All  corrective  work  must  be  done  without  causing  nerve  shock. 
Attention  to  the  general  health  by  a  liberal  diet,  fresh  air,  moderate 
exercise,  and  residence  in  a  dry,  warm  climate  are  indicated. 

Prognosis.  Pronounced  structural  changes  are  incurable.  In 
favorable  cases  the  process  can  be  checked,  the  function  of  the 
joint  be  partly  restored,  and  the  enlargement  reduced. 


CHAPTER  XXVIII 
DISTURBANCES  OF  METABOLISM 

DIABETES  MELLITUS 

(Glycosuria;   melituria) 

Diabetes  mellitus  is  a  nutritional  disorder  characterized  by 
excess  of  grape-sugar  in  the  blood  and  its  excretion  in  the  urine 
and  attended  by  polyuria  and  progressive  emaciation. 

Etiology.  A  posterior  middle  and  lower  thoracic  curvature, 
especially  containing  "rotary"  lesions,  is  a  common  predisposing 
factor.  Lesions  involving  the  tenth  thoracic  are  also  reported. 
Septic  foci  with  systemic  poisoning  may  be  a  factor.  Other  pre- 
disposing factors  are  Hebrew  race,  male  sex,  between  40  and  60 
years,  worry,  nervous  shock,  gout,  sexual  excesses,  syphilis,  and 
excessive  use  of  farinaceous  foods  and  malt  liquors. 

Injuries  or  diseases  of  the  brain  or  cord,  especially  to  the  floor 
of  the  fourth  ventricle,  and  diseases  of  the  pancreas,  have  borne 
a  causal  relation  to  this  affection.  Disease  of  the  liver  and  of  the 
kidneys  may  produce  glycosuria. 

Childhood  is  not  exempt  from  this  disease;  it  is  speedily  fatal 
in  the  young. 

"The  pathogenesis  is  not  known.  Disease  of  the  pancreas,  especially  of  the 
Islands  of  Langerhans,  may  be  responsible  for  a  lack  of  the  glycolytic  ferment 
normally  formed  in  these  bodies.  Disturbance  in  the  internal  secretion  of  the 
posterior  lobe  of  the  pituitary  body  is  associated  with  glycosuria.  The  secretion 
of  the  suprarenal  glands  seems  to  be  necessary  to  normal  action  of  the  pan- 
creatic islands,  and  disease  of  the  adrenals  is  one  factor  in  diabetes.  The 
glycogenic  activity  of  the  liver  may  be  disturbed  by  disease  of  that  organ  or  of 
its  nerve  and  glycosuria  result.  This  type  is  less  serious  and  fatal  than  is  that 
due  to  the  disease  of  the  ductless  glands.  Injury  to  the  nervous  system,  espe- 
cially to  the  floor  of  the  fourth  ventricle,  causes  diabetes.  Brain  tumors,  etc.,' 
may  have  glycosuria  as  an  early  symptom.  Nervous  shock,  emotional  storms, 
etc.,  produce  glycosuria  in  certain  individuals;  rarely,  such  a  shock  may  induce 
a  very  rapidly  fatal  diabetes. 

"The  pancreas  and  liver  receive  their  secretory  nerves  from  the  eighth  to 
the  tenth  thoracic  segments.  Bony  lesions  which  disturb  the  normal  balance 
of  these  centers  are  important  in  perpetuating  glycosuria,  and  in  predisposing 
to  diabetes.  In  a  number  of  cases  reported  by  osteopathic  physicians,  the  sugar 
appeared  in  the  urine  whenever  such  lesions  were  permitted  to  recur. 

"The  lesions  I  have  found  may  be  summarized:  (1)  In  the  lower  dorsal 
and  lumbar,  marked  posterior  curvatures ;  (2)  pressure  lesions  at  the  atlas, 
axis,  clavicle,  first  two  ribs,  fourth  and  fifth  dorsal,  in  relation  to  the  heads  of 
the  ribs  (sympathetic)  ;  (3)  in  acute  cases  there  is  intense  muscular  contraction 
in  the  lower  dorsal  and  lumbar  regions."— J.   M.  Littlejohn. 

Diagnosis.  Diabetes  is  to  be  suspected  when  a  patient  com- 
plains of  thirst,  hunger,  polyuria,  boils  and  carbuncles,  pruritus, 

279 


280  DISTURBANCES  OF  METABOLISM 

debility,  impotence,  or  loss  of  weight.  Constant  elimination  of 
sugar,  increased  urea,  constant  marked  polyuria,  and  loss  of  weight 
establish  the  diagnosis.  The  history  varies  according  to  several 
factors.  The  disease  has  the  more  rapidly  fatal  course  in  the 
young;  in  old  people  it  may  persist  for  years  without  causing  any 
serious  symptoms. 

Acute  Diabetes'  is  usually  found  in  the  comparatively  young, 
even  in  children ;  the  symptoms  very  rapidly  assume  a  grave  type 
and  post-mortem  the  pancreas  is  found  extensively  diseased.  It 
may  terminate  in  four  or  five  weeks. 

Chronic  Diabetes.  The  symptoms  are  often  obscure.  Except 
for  the  peculiar  urine,  and  attacks  of  dyspepsia,  the  patients  may 
obtain  a  fair  degree  of  health  for  a  long  time.  A  typical  case 
has  characteristic  symptoms;  polyuria,  hyperorexia,  and  poly- 
dipsia with  progressive  muscular  weakness  and  emaciation,  and 
loss  of  sexual  power.  The  tongue  is  irritable,  beefy-red,  often 
cracked,  and  glazed ;  the  mouth  is  dry  and  the  gums  swollen  and 
spongy  with  marginal  gingivitis ;  the  skin  is  harsh,  dry,  sallow,  and 
often  intensely  itchy ;  the  countenance  assumes  a  distressed"  and 
worn  expression ;  the  bowels  are  constipated  with  pale,  dry  stools. 
The  irritating  urine  causes  constant  itching,  burning,  and  uneasy 
sensations  along  the  urethra  and  at  the  meatus.  Lumbar  pain  is 
common.  There  may  be  severe  attacks  of  diabetic  dyspnea  or 
air-hunger.  The  breath  has  a  peculiar  sweetish,  apple-like  odor 
due  to  acetone.  The  onset  of  coma  is  often  sudden  but  patients 
frequently  die  of  intercurrent  disease  as  pneumonia,  critical  diar- 
rhea, and  other  infections. 

Diabetic  coma  occurs  in  one  of  three  ways:  Suddenly,  after 
exertion ;  gradually,  with  headache,  delirium,  dyspnea,  very  heavy 
sweetish  odor  to  the  breath  and  sometimes  cyanosis;  abruptly, 
with  headache,  feeling  of  intoxication  and  rapidly  fatal  coma.  The 
coma  is  thought  to  be  due  to  B-oxybutyric  acid  in  the  blood. 

Complications.  Peripheral  neuritis  is  manifested  by  leg-cramps, 
knee-jerk  often  absent,  numbness,  tingling,  neuralgias  and  paralyses.  Herpes 
zoster  and  perforating  ulcer  of  the  foot  sometimes  occur.  Diabetic  tabes  is  a 
peripheral  neuritis  characterized  by  lightning  pains  in  the  legs,  loss  of  the 
patellar  reflex,  and  pecuHar  high  steppage  gait.  Melancholia  is  frequent.  Cutane- 
ous effects  include  boils,  carbuncles,  eczema,  pruritis  of  the  vulva  and  pudendi, 
painful  onychia  and  gangrene  of  the  extremities.  Acute  pneumonia,  gangrene 
of  the  lung,  and  tubercular  lung  conditions  are  common.  Cataract  is  liable  to 
occur  and  progress  with  great  rapidity  in  young  persons.  Retinitis,  hemorrhages, 
sudden  amaurosis,  optic  atrophy,  and  paralysis  of  the  muscles  of  accommodation 
occur. 

Otitis  media  and  mastoiditis  are  infrequent.  Impotence  is  nearly  always 
present;  this  may  be  the  first  recognizable  symptom.  Conception  is  rare  and 
if  it  occurs,  abortion  is  likely. 

Blood.  Polyc3''themia  is  not  uncommon  with  marked  polyuria 
due  to  the  concentration  of  the  blood.    Hyperglycemia  is  present 


DIABETES  MELUTUS  281 

in  the  plasma,  often  as  high  as  0.57%  instead  of  the  normal  0.15%. 
Lipemia  is  present.  The  fat  may  form  a  creamy  layer  on  the  top 
of  clotted  blood.  Leucocytosis  and  anemia  may  supervene  in 
diabetic  coma.  Blood  pressure  is  usually  subnormal  in  uncompli- 
cated cases. 

Urine.  The  quantity  is  large,  3,000  to  20,000  cc.  (6  to  40  pts.) 
per  diem,  and  generally  in  direct  ratio  to  the  amount  of  sugar  pres- 
ent. The  color  is  clear,  very  pale,  greenish-yellow,  and  watery, 
becoming  opalescent  upon  standing.  Reaction  is  generally  acid. 
The  specific  gravity  is  usually  1025  to  1050. 

The  urea  is  increased.  The  normal  solids  are  relatively  dimin- 
ished. Preceding  and  during  diabetic  coma,  they  are  relatively 
and  absolutely  diminished.  The  phosphates  and  calcium  salts 
are  markedly  increased.  Uric  acid  is  not  increased.  The  daily 
quantity  of  sugar  varies  from  0.5  to  12%  or  20  gms.  to  500  gms.  in 
24  hours.  Glycogen  may  be  present.  Albumin  is  present  in  very 
small  amounts  in  the  early  stages. 

In  the  late  stages,  acetone,  diacetic  acid  and  B-oxybutyric  acid 
are  present.  Occasional  hyaline  and  finely  granular  casts,  mod- 
erate excess  of  squamous  epithelium  and  sometimes  leucocytes 
are  found. 

Albuminuria  with  later  cirrhosis  of  the  kidneys  and  the  symp- 
toms arising  therefrom  occur.  Edema  of  the  feet  and  ankles  is 
due  to  the  renal  disturbance. 

Diabetic  Diarrhea  is  very  easily  provoked  and  this  should  be 
remembered  in  treatment. 

Treatment.  The  treatment  of  diabetes  must  rest  upon  a  recog- 
nition of  the  especial  factors  producing  the  condition  in  each  case. 
In  the  typical  case,  with  the  thoracic  lesions  mentioned,  the  cor- 
rective work  is  certainly  indicated. 

"The  corrective  work  should  be  not  only  applied  to  the  dorso-lumbar  curve, 
but  to  relieving  the  approximation  between  the  occiput  and  atlas.  *  ♦  *  Cor- 
rective work  should  at  first  be  given  three  times  weekly;  later,  twice  weekly, 
and  still  later,  once  weekly.  Follow  up  your  case  with  occasional  treatment  and 
urinalysis  to  be  sure  you  have  a  permanent  result. 

"In  addition  to  the  corrective  work,  by  which  I  mean  the  replacement  to 
normal  position  and  securing  of  normal  motion  of  the  spine  throughout  the 
region  of  the  curve,  we  must  treat  the  liver  direct. 

"Next  in  importance  to  treatment  is  the  limitation  of  the  quantity  and  quality 
of  the  food.  And  I  am  inclined  to  believe  that  the  limitation  of  the  quantity, 
so  as  not  to  overwork  the  already  crowded  organs  of  assimilation,  is  of  more 
importance  than  the  limitation  of  the  quality  of  food." — F.  H.  Smith. 

Diet.  In  determining  a  diet  for  a  diabetic  patient,  the  output 
of  urea  is  of  more  value  than  the  output  of  sugar,  so  far  as  his 
maintenance  of  strength  is  concerned.  If  the  urea  can  be  kept 
within  fairly  normal  limits,  the  prognosis  is  fairly  good.  The  best 
way  to  decide  an  efficient  diet  is  as  follows :  Give  the  patient  a  few 


282  DISTURBANCES  OF  METABOLISM 

charcoal  tablets;  put  him  v»pon  a  strictly  carbohydrate  free  diet. 
When  the  feces  become  black,  make  an  analysis  of  the  24  hour 
urine  each  day  for  three  days ;  if  the  findings  are  fairly  constant,  the 
test  may  be  terminated ;  if  the  findings  vary,  the  analyses  and  the 
carbohydrate  free  diet  must  be  kept  up  for  two  days  longer.  The 
amount  of  sugar  eliminated  upon  a  sugar-free  diet  indicates  the 
amount  of  sugar  that  his  perverted  metabolism  demands ;  and  will 
secure,  if  necessary,  from  proteids ;  even  from  his  own  body  tissues. 
Carbohydrates  to  the  equivalent  of  this  elimination  should  then 
be  added  to  the  diet,  and  more  charcoal  tablets  given.  When  the 
feces  are  again  black,  the  24  hour  analyses  are  to  be  repeated;  if 
the  sugar  is  being  eliminated  in  excess  of  that  given,  more  must 
be  added  to  the  diet;  and  these  tests  are  to  be  repeated  until  the 
sugar  intake  equals  the  sugar  output.  The  urea,  on  this  diet, 
should  be  about  normal;  the  weight  of  the  patient  constant,  and 
while  the  elimination  of  sugar  is,  no  doubt,  greater  than  would  be 
the  case  with  strictly  carbohydrate  free  diet,  yet  the  condition  of 
the  patient  is  much  better.  The  better  nutrition  and  strength  give 
a  better  prognosis  for  recovery  than  the  lessened  sugar  output 
with  increased  body  loss.  Some  patients  have  idiosyncrasies  for 
certain  forms  of  carbohydrate — one  can  handle  potato  but  not 
bread,  another  can  take  honey  but  not  potato,  another  can  handle 
oatmeal  with  ease,  and  so  on.  These  conditions  must  be  tested 
by  urinalysis,  since  patients  often  have  most  unbased  ideas  of 
these  things. 

In  more  severe  cases  the  full  Allen  diet  should  be  given.  In 
lighter  cases  a  careful  study  should  be  made  of  the  sugar  tolerance, 
and  different  carbohydrates  should  be  tested  :n  order  that  as  varied 
and  satisfactory  a  diet  as  possible  may  be  determined,  which  shall 
yet  be  free  from  danger  of  increasing  the  progress  of  the  disease. 

"The  excretion  of  quantities  of  sugar  overworks  the  kidneys,  making  them 
liable  to  specific  kidney  ailments.  There  is  a  very  considerable  variety  of  foods 
that  a  diabetic  can  take  with  impunity,  and  the  diet  should  be  as  well  balanced 
as  may  be  considering  the  fact  that  so  much  of  the  carbohydrate  food  must  be 
forbidden.  *  *  * 

A  careful  distinction  that  must  be  made  between  the  foods  which  really 
contain  little  or  no  sugar,  and  those  which  seem  to  have  none  but  in  reality 
contain  it ;  for  example,  sour  milk  and  buttermilk — they  are  often  given  to  a 
diabetic  where  sweet  milk  is  forbidden.  In  the  sour  milk  the  sugar  is  still 
present  and  the  taste  merely  concealed  by  the  lactic  acid.  And  again  "tart" 
apples  are  prescribed  and  sweet  ones  barred.  The  sugar  again  is  present,  but 
simply  disguised  by  the  acid  taste." — H.  M.  Conklin. 

"An  absolute  withdrawal  of  carbohydrates  from  the  food  of  patients  having 
true  diabetes  melVtus  will  always  increase  the  acetone  and  diacetic  acid  and 
often  the  ammonia  and  B-oxybutyric  acid,  and  toxic  acidemia  and  coma  become 
imminent.  Hence,  it  is  unjustifiable,  sugar  having  been  discovered  in  the  urine, 
to  withdraw  the  starches  absolutely  or  too  rapidly  from  the  diet." — O.  T. 
Osborne. 

"There  is  danger,  then,  in  diabetes,  of  giving  too  much  meat  and  too  little 
carbohydrate,  for  meat,  aside  from  being  a  prolific  source  of  sugar,  leads  to 
the  formation  of  acid  products  in  the  process  of  metabolism  that  may  become 


DIABETES  INSIPIDUS  283 

dangerous;  meat  moreover,  in  diabetes  reduces  the  boundary  of  tolerance." — 
A.  C.  Croftan. 

The  patient  must  make  up  his  mind  to  lead  a  quiet  life,  avoid 
worry,  to  take  daily  systematic  exercise,  bathe  daily,  and  to  behave, 
in  short,  as  sensible,  well  people  do  in  every  way,  except  that  he 
must  avoid  overtire. 

The  great  thirst  may  be  relieved  by  lemon  juice,  ice,  or  small 
amounts  of  water  supped  slowly. 

The  pruritis  is  relieved  by  cooling  lotions  of  boric  acid  or 
hyposulphate  of  soda  (1  oz.  to  1  qt.  of  water).  In  coma,  inhala- 
tions of  oxygen  may  be  necessary. 

Prognosis.  In  these  days  true  diabetes  is  regarded  as  curable. 
The  younger  the  patient,  the  more  likely  and  more  rapid  the  fatal 
issue.  In  advanced  cases,  the  outlook  is  grave.  Patients  past  mid- 
dle life  may  not  suffer  any  serious  inconveniences  from  the  condi- 
tion, provided  they  have  proper  care. 


DIABETES  INSIPIDUS 

(Polyuria) 

Diabetes  insipidus  is  a  rare  condition  characterized  by  the 
passage  of  an  excessive  quantity  of  pale  limpid  urine,  free  from 
sugar  or  albumin  and  accompanied  by  insatiable  thirst. 

Etiology.  It  is  probably  due  to  the  presence  of  an  exces- 
sive amount  of  internal  secretion  of  pars  media  of  the  hypophysis 
in  some  cases.  It  has  been  experimentally  produced  by  implan- 
tation of  this  tissue,  and  persons  suffering  from  other  pituitary 
diseases  often  have  also  diabetes  insipidus.  The  essential  feature 
is  the  inability  of  the  kidneys  to  secrete  urine  of  high  osmotic 
tension.  Severe  nervous  shock,  diseases  of  the  brain,  or  suddenly 
produced  bony  lesions  affecting  the  eleventh  and  twelfth  thoracic 
segments,  may  cause  marked  polyuria. 

No  constant  structural  changes  are  noted.  The  most  common 
are  the  result  of  the  polyuria — hypertrophy  of  the  bladder  and  dila- 
tation of  the  ureter  and  renal  pelvis. 

Diagnosis.  The  main  symptoms  are  the  polyuria  and  great 
thirst.  The  appetite  is  sometimes  voracious;  there  are  headache, 
dyspepsia,  constipation,  mental  irritability,  muscular  weakness, 
severe  lumbar  pain.  The  mouth  is  dry,  and  thirst  severe.  The 
health  may  be  undermined  by  the  persistent  thirst  and  the  frequent 
micturition.  The  ability  of  the  kidneys  to  secrete  urine  of  high 
specific  gravity  should  be  tested.  Give  the  patient  very  little  water, 
with  a  salty  diet.  If  urine  of  high  specific  gravity  be  voided,  the 
condition  is  one  of  symptomatic  polyuria,  and  should  yield  readily 
to  correction  of  the  vertebral  lesions  mentioned,  with  good  hygiene. 


284  DISTURBANCES  OF  METABOLISM 

If  the  urine  is  still  of  low  specific  gravity,  the  true  diabetes  insip- 
idus is  probably  present.  The  X-ray  should  be  used  to  determine 
the  size  and  shap.e  of  the  sella  turcica. 

The  spinal  examination  often  shows  lesions  of  the  ninth  to 
twelfth  dorsal  vertebrae  and  the  corresponding  ribs. 

Urine.  The  quantity  is  increased  to  6,000  to  30,000  cc.  per  day. 
The  color  is  very  pale ;  the  reaction  is  faintly  acid  or  neutral. 
Upon  standing  it  becomes  ammoniacal  and  turbid,  and  often  has 
an  offensive,  fish-like  odor;  the  specific  gravity  is  low,  1001  to 
1005;  the  normal  solids  are  absolutely  much  increased  but  rela- 
tively much  diminished.  The  total  urea  is  greatly  increased;  the 
chlorides,  phosphates,  and  sulphates  ar-e  high.  Sugar  and  albumin 
are  usually  absent.  Sediment  is  very  slight,  of  cellular  elements, 
squamous  epithelium  and  small  round  cells. 

Treatment.  In  true  diabetes  insipidus,  when  the  pituitary  is 
involved,  treatment  must  be  devoted  to  that  gland.  Usually  other 
symptoms  appear  early,  and  the  urinary  condition  evades  notice. 
The  urinalyses  should  be  made,  carefully  grading  the  water  intake, 
until  just  enough  water  is  given  to  dissolve  and  carry  away  the 
total  body  wastes.  The  food  should  also  be  restricted  to  the 
actual  body  requirements,  in  order  that  the  urinary  solids  may  be 
kept  low.  In  nervou»  polyuria,  and  in  that  due  to  bony  lesions 
the  prognosis  is  much  better.  The  lesions  of  the  lower  thoracic 
region  are  to  be  corrected.  Springing  the  spinal  column  gently 
gives  immediate  relief  in  many  cases.  The  diet  should  be  almost 
or  quite  free  from  sodium  chloride;  fruits  and  raw  vegetables 
should  be  freely  used  as  foods.  Meat  should  be  reduced  in  most 
cases;  many  patients  do  better  upon  a  rather  low  proteid  intake. 
Regular  and  systematic  exercise  in  the  open  air  is  very  beneficial. 
If  the  patient  is  of  neurotic  temperament,  the  educational  measures 
indicated  for  hysteria  may  be  needed ;  recurrences  may  follow  emo- 
tional storms  in  neurotic  patients. 

ACIDOSIS 

Acidosis  is  a  condition  of  metabolism  characterized  by  an  excess 
of  acid  radicles  in  the  blood  and  probably  in  the  tissues.  In  dia- 
betes mellitus,  starvation,  high  fevers,  certain  wasting  diseases, 
diet  lacking  in  carbohydrates,  and  in  other  conditions,  there  is 
an  accumulation  of  certain  acid  products  of  fat,  or  proteid,  decom- 
position. These  include  acetone,  beta-oxybutyric  and  aceto-acetic 
acids,  and  other  acids  of  the  volatile  series.  Diabetic  acidosis  is 
associated  with  weakness,  stupor  or  somnolence,  and  later  coma 
and  death. 

In  other  conditions,  not  well  understood,  there  is  faulty  neutrali- 
zation of  the  mineral  acids.    This  may  be  due  to  lack  of  alkaline 


•  ACIDOSIS  285 

salts  in  the  foods ;  to  imperfect  oxidation ;  to  defective  metabolism, 
or  it  may  be  due  to  defective  elimination  of  the  urinary  acids. 
There  is  lowered  carbon-dioxide  tension  in  the  alveoli,  air-hunger 
and  hyperpnea,  and  varying  nervous  and  digestive  symptoms.  Va- 
rious writers  attribute  a  great  number  of  ills  to  acidosis,  some  of 
which  may  perhaps  be  due  to  the  condition.  When  these  acid 
wastes  (the  poorly  oxidized  katabolites)  accumulate  in  the  blood, 
they  are  usually  neutralized  by  the  use  of  a  moiety  of  the  proteid 
molecule,  broken  up  into  ammonia  and  other  radicals.  The  amount 
of  urinary  ammonia  thus  gives  a  fairly  accurate  indication  as  to 
the  amount  of  acidosis  present.  Another  indication  is  found  in 
the  increase  in  the  respiratory  rate — this  is  due  to  the  stimulation 
of  the  respiratory  center  by  the  increased  acidity  of  the  blood. 

Acidosis  should  not  be  confused  with  diseases  due  to  food  de- 
ficiencies. For  example,  beri-beri  is  due  to  a  loss  of  certain  ele- 
ments, probably  those  called  "vitamins."  If  these  are  replaced, 
even  without  any  alkaline  substances  being  added,  the  patient  re- 
covers. In  scurvy,  other  substances  seem  to  be  lacking,  though 
so  far  the  nature  of  these  substances  is  not  known.  The  addition 
of  lime  juice  to  the  diet  gives  immediate  relief,  though  this  con- 
tains too  small  an  amount  of  alkaline  salts  to  neutralize  any  great 
amount  of  acids.  Neither  beri-beri  nor  scurvy  are  relieved  by  the 
use  of  alkaline  substances,  unless  these  contain  the  valuable  vita- 
mins or  other  "vital"  substances.  Acidosis,  on  the  other  hand, 
yields  quickly  to  the  administration  of  alkaline  foods  or  soda, 
though  these  may  be  cooked  or  may  be  inorganic.  The  confusion 
resulting  from  an  attempt  to  include  all  diseases  due  to  food  defi- 
ciencies under  acidosis  is  regrettable. 

Treatment.  Acidosis  characterized  by  acetone  in  the  breath, 
and  acetone,  beta-oxybutyric  and  aceto-acetic  acids  in  the  urine, 
must  be  met  by  the  administration  of  carbohydrates;  oatmeal  is 
perhaps  the  most  useful  of  these,  though  other  forms  of  starch 
or  sugar  may  be  better  adapted  to  special  conditions.  (See  dia- 
betes mellitus.) 

Acidosis  characterized  by  excess  of  urinary  ammonia  must 
receive  different  treatment.  Carnivorous  animals  or  human  sub- 
jects suffer  less  from  this  form  of  acidosis  than  do  vegetarians; 
this  is  because  they  have  a  larger  available  supply  of  ammonia 
with  which  to  neutralize  the  acids.  This  iorm  of  acidosis  must  be 
met  by  the  administration  of  alkaline  salts,  preferably  in  the  form 
of  the  vegetable  compounds.  Raw  vegetables,  such  as  lettuce,  cel- 
ery, carrots,  onions,  cabbage,  and  others  are  useful. 

Every  effort  must  be  made  to  increase  the  oxygen  supply  and 
its  use  by  the  tissues.  Respiration,  circulation,  the  blood  itself 
and  the  internal  secretions  should  all  be  investigated,  and  whatever 
abnormal  conditions  are  found  should  receive  suitable  treatment. 


\ 

286  DISTURBANCES  OF  METABOLISM 

Acidosis  is  a  symptom  of  many  varying  states,  and  it  must 
everywhere  be  treated  according  to  its  underlying  causes.  Much 
more  study  is  needed  before  we  are  ready  to  consider  these  ques- 
tions answered. 

RACHITIS 

(Rickets) 

Rickets  is  a  chronic  nutritional  disorder  occurring  in  infants 
and  very  young  children,  attended  by  changes  in  the  development 
of  the  bones  and  clinically  characterized  by  wasting,  stunted 
growth,  characteristic  physiognomy  and  deformity. 

Etiology.  The  real  cause  is  unknown.  It  usually  develops 
between  the  sixth  and  fifteenth  months  of  age;  from  improper 
feeding,  especially  that  poor  in  animal  fat  and  protein ;  bad  hygiene, 
including  lack  of  sunlight;  lack  of  exercise;  overcrowding,  and 
other  conditions  associated  with  extreme  poverty  or  lack  of  sani- 
tation. "Good"  babies,  left  too  long  lying  quietly,  are  apt  to  suffer 
from  rachitis.  Milk  which  has  been  cooked,  or  any  of  the  prepared 
foods,  used  to  the  exclusion  of  fresh  milk,  or  foods  too  largely  car- 
bohydrate, all  are  deficient  in  certain  compounds  required  for  the 
development  of  the  skeleton.  It  is  not  merely  a  lack  of  lime  that 
is  responsible  for  the  disease,  since  this  is  sufficiently  supplied  by 
those  diets  which  appear  most  harmful.  Breast  milk,  when  this  is , 
deficient  in  quality,  may  cause  rickets,  as  do  the  artificial  foods. 
The  disease  is  found  in  the  new  born;  and  some  infants  are  born 
with  evidences  of  having  suffered  before  birth.  It  is  supposed  that 
maternal  mal-nutrition  is  the  cause  of  this  condition.  Family 
history  of  rachitis,  syphilis,  tuberculosis,  and  certain  other  wasting 
diseases  also  predispose  to  the  disease. 

Diagnosis.     There  are  three  early  pathognomonic  symptoms: 

(1)  profuse  sweating  of  the  head  and  neck,  especially  during  sleep; 

(2)  restlessness  at  night,  as  if  the  weight  of  the  clothing  is  uncom- 
fortable— as  it  probably  is — this  occurs  even  if  the  room  is  cold; 

(3)  the  child  lies  unduly  quiet  when  left  alone,  and  cries  as  if 
with  pain  when  handled.  These  symptoms,  especially  the  last, 
should  arouse  a  suspicion  of  rickets,  even  when  no  digestive  dis- 
turbances have  manifested  themselves.  A  slight  fever,  some 
diarrhea  and  constipation,  increasing  weakness  and  fretfulness, 
and  usually  emaciation,  may  precede  the  bone  changes  for  weeks, 
sometimes  for  months.  An  abnormal  fat  may  be  present,  instead 
of  emaciation.  The  changes  in  the  ribs,  later  of  other  bones,  and 
the  bending  of  the  long  bones,  with  or  without  recognizable 
fracture,  may  be  noticed  early,  or  may  not  attract  attention  until 
the  deformity  becomes  very  serious.  When  the  disease  is  well 
developed,  the  appearance  of  the  child  is  characteristic.  The  long 
bones,  ribs,  and  skull  are  chiefly  affected.    The  linje  salts  are  much 


RACHITIS  287 

diminished  in  amount;  the  cartilaginous  epiphyses  are  thickened; 
ossification  and  dentition  are  delayed  and  when  taking  place  are 
imperfect.  Periosteal  proliferation  causes  thickening  of  the  flat 
bones  of  the  skull  but  ossification  is  slow  so  that  the  fontanelles 
remain  open  an  abnormally  long  time.  The  occipital  bone  is  apt  to 
be  thinned  so  that  it  may  crackle  under  the  fingers  (parchment 
crackling  or  craniotabes). 

The  head  is  elongated  from  back  to  front,  flat  on  top,  the 
forehead  square  and  overhanging,  the  fontanelles  slow  in  closing, 
the  skull  sutures  prominent  if  ossification  is  complete,  the  maxilla 
flattened,  and  the  skin  veins  distended.  Raised  areas,  "bosses," 
may  be  felt  on  the  skull.  The  face  appears  small  in  proportion  to 
the  rest  of  the  head  but  may  be  plump.  The  ribs  show  a  charac- 
teristic "beading"  at  the  junction  of  the  costal  cartilages  (rickety 
rosary),  this  being  usually  the  first  change  noted.  Pressure  of  the 
external  air  on  the  softened  anterior  ends  of  the  ribs  produces  the 
"rickety  chest"  marked  by  a  shallow  vertical  depression  on  each 
side  of  the  sternum.  "Pigeon  breast"  and  "Harrison's  grooves" — a 
transverse  depression  running  from  the  xiphoid  cartilage  toward 
the  axilla — are  due  to  impeded  inspiration. 

The  legs  are  bowed  or  sickle-shaped,  showing  well-marked 
epiphyseal  enlargements,  especially  at  the  lower  ends  of  the  tibia. 
The  pelvis  is  often  much  deformed,  being  of  later  significance  in 
the  female  in  regard  to  parturition.  The  arms  show  the  most 
marked  changes  at  the  lower  ends  of  the  ulna  and  radius.  The 
humerus  and  clavicle  may  be  affected. 

The  spine  may  be  kyphotic.  Scofiosis  is  not  so  common.  The 
deformities  of  the  limbs  are  largely  due  to  yielding  of  the  softened 
bone  to  mechanical  pressure  hence  rickety  subjects  must  avoid 
any  undue  strain  such  as  walking  or  using  the  arms.  The  mind 
may  be  deficient;  the  body  stunted  and  emaciated;  the  abdomen 
is  prominent  from  flatulent  distention  and  from  enlargement  of 
the  liver  and  spleen;  muscular  weakness  is  marked  and  digestive 
disturbances  are  common.  Mental  development  is  usually  retarded, 
though  with  better  nutrition  these  children  may  attain  normal 
minds  later. 

The  blood  presents  the  picture  of  secondary  anemia,  sometimes 
of  the  chlorotic  type;  sometimes  developmental.  A  slight  lym- 
photosis  may  be  present ;  it  must  not  be  forgotten  that  lymphocytes 
are  high  in  normal  children's  blood. 

Among  the  complications  are :  Pulmonary  diseases ;  tetany ; 
laryngismus  stridulus;  convulsions;  adenoids  and  hypertrophied 
tonsils;  green-stick  fractures  are  frequent.  The  disease  predis- 
poses to  the  various  afl"ections  6f  childhood.  These  must  be  kept 
in  mind  during  the  treatment. 


288  DISTURBANCES  OF  METABOLISM 

Treatment.  The  main  treatment  is  to  correct  the  causes,  dietetic 
and  hygienic.  If  the  mother  is  unhealthy,  she  must  stop  nursing 
the  child,  placing  it  with- a  healthy  wet-nurse  if  possible,  or  upon 
artificial  feeding,  cow's  milk  suitably  modified  to  the  age  of  the 
baby  being  the  essential  element  during  the  first  year  of  life. 
Goat's  milk  is  better  than  cow's  milk.  Barley  water  or  oatmeal 
gruel  properly  made  and  strained  are  excellent  additions  to  the 
milk  and  aid  in  keeping  the  bowels  in  a  normal  condition.  Plenty 
of  good  water  should  be  given.  Orange  juice  an  hour  before 
feeding;  olive  oil  at  night,  according  to  the  age  of  the  child,  may 
be  added  to  the  diet. 

The  older  child  can  have  beef  juice,  light  meats,  eggs,  green 
vegetables  and  fruits  according  to  his  age.  A  large  proportion  of 
fat  is  a  good  addition. 

A  daily  warm  bath  is  necessary.  An  olive  oil  rub  aids  in  nutri- 
tion ;  no  oil  is  absorbed,  but  its  use  keeps  the  skin  soft,  and  gives 
comfort. 

The  clothing  should  be  light,  yet  warm.  The  child  should  be 
well  wrapped  up  and  kept  in  the  open  air  and  sunshine,  shading 
the  eyes,  as  much  as  possible.  No  attempt  to  persuade  the  child 
to  use  his  arms  or  legs  is  permissible,  until  the  general  nutrition 
is  recognizably  bettered;  walking  must  be  prevented  until  the 
child  is  thoroughly  strong.  Gentle  massag-e  of  the  arms  and  legs, 
with  very  gentle  pulling  and  attempts  to  straighten  them  out,  may 
help  in  correcting  deformities  already  present,  and  prevent  further 
distortions. 

The  spinal  curve  usually  yields  readily  to  manipulative  treat- 
ment, supplemented  by  posture.  The  child  should  not  be  per- 
mitted to  lie  upon  one  side,  or  to  maintain  any  position  too  long. 

The  limb  deformities  may  be  outgrown  if  mild  and  the  proper 
manipulation  is  employed,  or  may  require  braces  or  orthopedic 
surgery. 

The  active  symptoms  cease  when  the  child  reaches  the  age  of 
eighteen  to  twenty-four  months.  The  earliest  signs  of  recovery 
are  a  diminution  of  the  nervousness,  increased  muscular  strength, 
diminution  of  the  head  sweats,  and  disappearance  of  craniotabes. 
Improvement  is  slow  but  progressive  as  there  are  seldom  relapses. 

Prognosis.  The  disease  is  not  fatal  in  itself  but  renders  the 
child  very  susceptible  to  intercurrent  aflfections,  especially  those 
of  the  respiratory  tract. 

,  A  condition  called  Late  Rickets  or  delayed  rickets,  may  appear 
at  any  time  from  four  to  twelve  years,  and  is  usually  due  to  some 
severe  infectious  disease.  The  symptoms  and  bony  disturbances 
are  atypical.  Fractures  at  the  epiphyses  are  frequent.  During 
puberty,  a  form  of  malnutrition  with  some  rachitic  symptoms  may 
appear;  this  is  often  present  in  overfat  boys,  and  the  fracture  of 
the  femur  may  simulate  hip  joint  disease.    It  seems  to  be  due  to 


SCORBUTUS  289 

some  disturbance  of  the  pituitary  secretion,  and  is  associated  with 
delayed  puberty. 

SCORBUTUS 

(Scurvy;  scorbutic  purpura) 

Scorbutus  is  a  nutritional  disorder  characterized  by  great  debil- 
ity, a  spongfy  condition  of  the  gums,  a  tendency  to  hemorrhage, 
and  anemia. 

Etiology.  It  is  due  to  improper  and  insufficient  food,  espe- 
cially lack  of  fresh  vegetables,  and  insanitary  surroundings.  It  is 
rare  except  in  Russia.  A  very  mild  form  appears  among  people 
living  upon  a  diet  chiefly  of  canned  or  dried  foods,  especially  with 
salt  meats  in  too  great  proportion. 

Diagnosis.  The  onset  is  gradual.  The  patient  becomes  weak 
and  thin,  drowsy  or  languid,  with  more  or  less  general  aching  of 
the  bones.  The  gums  are  soft  and  swollen,  bleeding  easily  on 
the  slightest  pressure ;  the  tongue  is  coated  and  red,  the  skin  is 
dry,  rough  and  sallow;  diarrhea. alternates  with  constipation. 

As  the  disease  progresses,  the  teeth  may  fall,  the  mouth  ulcer- 
ate and  emit  an  intensely  fetid  odor.  Petechiae  around  the  hair 
follicles  or  large  subcutaneous  extravasations  appear  on  the  exten- 
sor aspects  of  the  limbs.  Epistaxis  or  subconjunctival  hemorrhages 
may  be  annoying.  Death  may  occur  from  hemorrhages  into  the 
body  cavities.  Hard,  brawny,  tender  swellings  of  the  calves  are 
due  to  subcutaneous  and  intramuscular  hemorrhages. 

The  patients  present  a  cachectic  appearance.  Sometimes  a 
peculiar  night  blindness  develops  which  is  dependent  upon  the  ex- 
haustion of  the  retina. 

Infantile  Scurvy  or  Barlow's  Disease  is  sometimes  present  in 
children  fed  constantly  with  proprietary  foods ;  occurs  most  fre- 
quently between  the  ages  of  six  and  twenty  months,  and  is  marked 
by  tenderness  of  the  limbs,  and  weakness.  Exclusive  diet  of  malted 
milk,  condensed  milk,  various  baby  foods,  and  sterilized  milk  are 
the  causative  factors. 

Diagnosis.  The  legs  are  kept  drawn  up  and  still.  When  these 
are  moved  there  is  continuous  crying.  The  child  grows  cachectic. 
Some  obscure  swellings  may  be  found,  ill-defined,  but  resembling 
thickenings,  around  the  shafts  of  the  bones.  Crepitus  may  be 
found  in  epiphyseal  regions,  due  to  separation  of  shaft  and  epiph- 
ysis. Proptosis  of  one  or  both  eyes  with  puffiness  and  very  slight 
staining  of  the  upper  lid  appears.  A  profound  anemia  develops. 
The  complexion  becomes  sallow  or  earthy-colored  and  small 
ecchymotic  petechiae  appear  upon  various  parts  of  the  body. 
Asthenia  is  well  marked  but  emaciation  is  not  so  apparent.    The 


290  DISTURBANCES  OF  METABOLISM 

temperature  is  erratic.  If  teeth  have  appeared,  the  gums  may 
become  spongy  and  bleed. 

The  heart  may  show  a  hemic  murmur,  the  impulse  is  feeble  and 
irregular. 

Subluxations  are  apt  to  be  found  in  the  splanchnic  area.  The 
urine  is  high-colored,  of  high  specific  gravity,  the  phosphates  are 
increased,  there  is  often  blood  and  albumin.  The  blood  is  that  of 
severe  secondary  anemia. 

Treatment.  The  most  important  factor  is  the  diet.  Give  first 
a  little  lime  juice  or  lemon  juice  in  water.  Good  soup  with  raw 
vegetable  juices,  in  very  small  quantities  at  first,  may  be  added.  As 
soon  as  the  digestion  will  permit  a  mixed  diet — with  amounts  of 
fresh  fruit  and  vegetables — leads  to  rapid  recovery.  In  the  infan- 
tile form,  breast-feeding  should  be  employed  if  possible.  Properly 
modified  cow's  or  goat's  milk  may  be  used.  Orange  juice  should  be 
given,  one  tablespoonful  four  times  a  day,  one  hour  before  feeding. 
Normal  saline  or  other  bland  solutions  should  be  used  as  a  mouth 
wash,  several  times  a  day.  Other  treatment  depends  upon  con- 
ditions as  found  on  examination. 

Prognosis.  Recovery  is  the  rule  if  appropriate  treatment  is 
instituted  early. 

Prophylaxis  consists  in  good  feeding  and  good  hygiene.  Too 
great  a  proportion  of  canned  and  salt  meats  are  to  be  avoided. 


OBESITY 

(Including  corpulence;   lipomatosis  universalis;   polysarcia  adiposa;   Dercum's 
disease;  adiposa  dolorosa) 

Obesity  is  a  nutritional  disorder  characterized  by  an  abnor- 
mally increased  deposit  of  fat  in  the  body.  It  begins  insidiously, 
and  by  its  presence  weakens  the  muscular  and  glandular  tissues 
of  the  body. 

Etiology.  Several  classes  are  recognized.  The  plethoric  type 
is  the  result  of  habitual  overnutrition.  Persons  who  constantly 
assimilate  even  a  very  little  more  food  than  they  utilize  each  day, 
must  inevitably  put  on  weight;  this  process  continued  for  years, 
results  first  in  uncomfortable  weight,  then  in  the  embarrassment  of 
the  active  organs,  and  pathological  states  aflfecting  almost  or  quite 
the  entire  body.  The  anemic  type  is  due  to  deficient  oxidation 
processes,  and  usually  follows  some  wasting  or  exhausting  disease, 
or  is  associated  with  chlorosis  or  cardiac  weakness.  Lack  of  cer- 
tain internal  secretions  may  be  responsible;  it  appears  in  men 
after  the  climacteric,  in  women  after  the  menopause,  or  during 
prolonged  lactation,  or  after  exhausting  child  birth,  or  who  suffer 
from  ovarian  disease.     Typhoid,  syphilis,  and  other  wasting  dis- 


OBESITY  291 

eases  may  be  followed  by  this  type.  The  hydremic  type  may 
follow  either  of  the  two  just  given,  or  may  be  directly  due  to 
cardiac  weakness,  arteriosclerosis  or  nephritis.  In  this  form  the 
connective  tissues  are  fatty,  but  are  also  slightly  edemic. 

Hypophysial  obesity  is  due  to  disease  of  the  pituitary  body;  it  is  asso- 
ciated with  delayed  development  of  the  genital  organs,  in  the  young,  or  with  their 
atrophy,  in  older  patients.  The  relation  of  disturbances  of  the  reproductive 
organs  with  ordinary  types  of  obesity  suggests  the  possibility  that  these  also 
may  be  due  to  deficient  activity  of  the  hypophysis.  In  this  form  the  use  of 
pituitary  extract  is  to  be  commended,  after  the  failure  of  ordinary  methods  of 
treatment. 

Adiposa  Tuberosa  is  characterized  by  the  deposit  of  lumps  or  tumors  of 
fat.  When  this  is  associated  with  general  lipomatosis,  the  prognosis  is  fairly 
good  for  improvement;  when  not  associated  with  the  generaHzed  condition,  it 
may  be  intractable.  The  tumors  are  often  painful.  The  term  Adiposa 
Dolorosa  (Dercum's  disease)  is  usually  appHed  only  to  those  cases  in  which 
the  fatty  deposit  is  localized  and  very  great,  as  in  the  abdomen,  the  neck,  or  the 
mammae.     It  may  be  exquisitely  painful. 

Bony  Lesions  in  obesity  vary  greatly.  In  the  form  due  pri- 
marily to  overnutrition  or  to  under  exercise,  the  spinal  condition 
is  good  in  the  beginning.  Later,  the  weight  of  the  abdominal 
organs  compels  overextension  of  the  spinal  column,  rigidity  of 
the  lower  thoracic  region,  and  variations  in  the  normal  spinal  con- 
tour. In  the  anemic  type,  the  spinal  variations  are  those  asso- 
ciated with  the  primary  disease.  In  many  cases  in  which  the  fatty 
deposit  appears  to  be  due  to  lack  of  oxydizing  ferments,  lesions 
of  the  eleventh  thoracic  are  present  and  seem  to  be  active  etiologi- 
cal factors.  Correction  of  this  lesion,  in  these  cases,  results  in 
gradual  return  to  the  normal,  even  with  no  change  in  exercise  or 
food  intake,  when  these  are  already  not  unhygienic. 

Heredity  is  a  strong  factor,  though  many  cases  supposed  to  be 
hereditary  are  due  to  family  habits  of  eating  and  exercise. 

Diagnosis.  The  recognition  of  the  condition  presents  no  diffi- 
culty. In  order  to  determine  what  causes  are  active  in  perpetu- 
ating the  disease  much  study  of  the  case  may  be  necessary.  The 
history  should  indicate  whether  the  disease  is  hereditary  or  is 
the  result  of  over-nutrition.  Examination  of  the  heart  with  a 
history  of  rheumatism  or  other  etiological  factor  in  cardiac  dis- 
ease ;  of  some  wasting  disease  just  previous  to  the  beginning 
of  obesity,  may  lead  to  useful  information  concerning  the  further 
treatment  of  the  case.  Gouty  forms  can  usually  be  recognized 
by  a  study  of  the  tirea-uric  acid  relationship.  An  examination 
of.  the  blood  may  explain  some  cases.  When  the  hypophysis 
is  at  fault  there  are  changes  in  the  genitals  and  in  adults  dis- 
turbances of  the  sex  feelings.  Symptoms  of  increased  intracranial 
pressure  are  present.     (See  brain  tumor.) 

Treatment.  Almost  as  many  methods  of  treatment  have  been 
advised  as  there  are  patients.    When  it  is  remembered  that  obesity 


292  .  DISTURBANCES  OF  METABOLISM 

is  not  a  disease  but  is  a  result  of  some  departure  from  the  normal 
structure  of  the  body  or  from  the  normal  care  of  the  body  it  is 
evident  that  every  patient  requires  some  special  care.  A  large 
proportion  of  cases  are  primarily  of  a  plethoric  type.  In  these 
cases  it  is  necessary  first  to  plan  a  diet  and  daily  regime  which 
shall  put  the  patient  into  nitrogen  and  carbon  equilibrium.  This 
done  the  amount  of  carbon  must  be  reduced  until  the  loss  of 
weight  becomes  established.  No  rule  can  govern  the  diet  list 
but  each  patient  is  a  law  to  himself.  The  fact  that  the  reduction  in 
carbohydrates  is  necessary  in  most  cases  is  due  to  the  fact  that  an 
excessive  intake  of  carbohydrates  is  habitual  with  many  people. 
Each  patient  must  be  given  exercises  which  also  are  adapted  to 
his  individual  case. 

Great  care  must  be  taken  to  avoid  heart  injury  in  advising  both 
diet  and  exercise  for  obese  patients.  Excessively  nitrogenous  diets 
may  seriously  embarrass  the  action  of  the  kidneys.  Too  great 
limitation  of  a  watery  intake  and  too  sudden  reduction  in  the  food 
as  well  as  too  violent  exercise  may  produce  serious  injury  to  the 
heart. 

In  young,  vigorous,  plethoric  subjects  the  most  rapid  loss  of 
weight  is  secured  by  the  following  regime :  Two  days'  fasting  with 
plenty  of  hot  water  to  be  taken  as  often  as  possible.  Third  day,  a 
plentiful  amount  of  a  single  nitrogenous  food,  such  as  milk,  cheese, 
meat,  eggs,  etc.  Fourth  day,  fast  with  hot  water.  Fifth  day, 
raw,  green  vegetables,  celery,  lettuce,  etc.,  as  freely  as  may  be 
desired.  Sixth  day,  fast  and  hot  water.  Seventh  day,  nitrogenous 
food,  and  so  on.  Fast  may  be  for  two  days  if  this  is  desired.  In 
outlining  such  a  regime  as  this  it  is  necessary  to  examine  the 
heart  and  to  analyze  the  urine  at  least  twice  each  week.  This 
plan  may  be  modified  by  omitting  the  day  of  fast  in  patients  who 
must  keep  on  working. 

When  obesity  is  complicated  with  anemia  or  endocrinic,  circu- 
latory or  other  organic  disturbances  great  care  must  be  exercised 
in  treatment.  A  high  cellulose  diet  especially  of  raw,  green  vege- 
tables is  usually  safe  and  often  efficient.  Ordinary  massage  is 
useful  in  the  hyperemic  or  anemic  form.  Violent  rubbing  may 
reduce  the  weight  temporarily.  The  same  is  true  of  baths,  sweats 
and  other  methods  especially  in  vogue  at  various  sanatoriums. 
Such  courses  of  treatment  reduce  the  weight  speedily  in  many 
cases,  but  unless  the  life  habits  of  the  individual  are  modified 
a  return  of  the  disease  is  to  be  expected.  When  there  is  rea- 
son to  suspect  that  obesity  is  due  to  lack  of  the  secretions  of 
the  ductless  glands  the  attempt  should  be  made  first  to  secure 
increased  activity  of  these  glands  through  controlling  their  circula- 
tion. When  this  is  found  impossible  and  when  the  condition  of 
the  patient  does  not  yield  to  ordinary  methods  of  treatment  the 
use  of  the  animal  extracts  of  the  gland  may  be  cautiously  begun. 


OBESITY  293 

From  what  has  been  said  it  is  evident  that  the  treatment  of  obesity- 
is  really  best  secured  by  the  treatment  in  each  case  of  the  factors 
which  cause  or  which  perpetuate  the  abnormal  fat  deposit. 

"The  cardinal  points  of  treatment  are:  first,  removal  of  osteopathic  lesions; 
second,  diet;  third,  baths;  fourth,  exercise  and  regulation  of  clothing.  The 
greatest  problem  in  treatment  is  the  dietary.  The  diet  may  be  reduced  as  much 
as  two-fifths  without  danger,  but  it  must  contain  normal  proportions  of  the 
proteins,  carbohydrates  and  fats.  In  other  words,  the  diet  should  be  a  mixed 
one." — Earl  Scammon. 

Prognosis.  The  outlook  depends  upon  the  nature  of  the  case. 
In  plethoric  subjects  in  whom  no  ordinary  disease  has  manifested 
itself  the  outlook  is  measured  absolutely  by  the  self-control  of  the 
individual.  Upon  a  wholesome  diet  with  normal  habits  of  life  his 
weight  can  be  kept  within  a  normal  limit  and  his  strength  and 
comfort  be  assured.  If  he  is  unwilling  to  control  himself  the  con- 
dition becomes  fixed  and  organic  disease  is  inevitable.  Older 
patients  and  those  in  whom  organic  disease  has  become  fixed 
should  be  permitted  to  lose  weight  only  gradually  and  should  be 
watched  carefully  to  prevent  complications.  Such  patients  do 
very  much  better  with  a  reduction  of  fatty  deposit  and  life  is  pro- 
longed as  well  as  made  more  comfortable  by  the  reduction  which 
need  not  be  very  great  in  amount.  The  most  efficient  prophylaxis 
is  based  upon  the  recognition  of  the  fact  that  when  the  carbon 
intake  exceeds  the  carbon  outgo  an  accumulation  of  fat  in  the  body- 
is  inevitable. 

Whether  there  is  an  abnormal  state  of  the  body,  so  that  less 
than  the  usual  amount  of  carbon  can  be  utilized,  or  whether  there 
is  simply  the  habitual  ingestion  of  too  great  an  amount  of  carbon 
in  food,  the  principle  still  remains,  that  one  who  assimilates  more 
carbon  than  he  eliminates  must  inevitably  store  fat ;  while  one 
who  habitually  assimilates  less  carbon  than  he  eliminates  must  as 
inevitably  lose  fat. 


CHAPTER  XXIX 
DISEASES  OF  THE  DUCTLESS  GLANDS 

GENERAL  DISCUSSION 

The  glands  of  the  body  which  elaborate  an  internal  secretion 
include  the  thyroid,  pituitary  body,  suprarenal  capsules,  the  islands 
of  Langerhan  in  the  pancreas,  the  ovaries  and  testes.  To  a  very 
much  less  marked  extent,  practically  every  other  organ  seems  to 
form  and  supply  to  the  body  substances  more  or  less  important 
to  the  general  metabolism.  The  liver  gives  off  urea  and  glu- 
cose into  the  blood  stream  though  these  are  not  of  the  same 
class  as  the  substances  elaborated  by  the  glands  first  mentioned. 
The  function  of  the  spleen  and  thymus,  the  hemolymph,  the  caro- 
tid and  the  coccygeal  glands,  as  w^ell  as  the  other  lymph  nodes  of 
the  body  must  be  mentioned  in  this  connection  though  their  func- 
tion has  not  yet  been  thoroughly  studied.  The  thyroid  may  be 
taken  as  an  example  of  a  ductless  gland.  The  thyroid  gland  is 
subject  to  three  types  of  diseases:  In  the  first  place  it  is  subject 
to  diseases  which  do  not  affect  its  functional  activity  to  any  great 
extent  as  is  the  case  in  simple  goiter.  Second,  diseases  may 
destroy  its  power  of  elaborating  its  internal  secretions,  as  is  the 
case  with  cretinism  or  myxedema.  Third,  diseases  may  increase 
the  functional  activity  of  the  gland  as  in  the  case  of  the  exophthal- 
mic goiter.  It  is  probable  that  further  study  will  demonstrate  these 
three  classes  of  disease  for  all  of  the  glands  which  elaborate  inter- 
nal secretions. 

Secretory  nerves  have  been  demonstrated  for  most  of  the  duct- 
less glands.  Vasomotor  nerves  are  distributed  through  all  of 
them.  All  have  extremely  plentiful  blood  supply  and  venous  and 
lymphatic  drainage  is  plentiful.  All  of  the  true  internal  secretions 
are  of  great  importance  to  the  general  metabolism  of  the  body  and 
it  is  usually  true  that  a  very  small  amount  of  the  secretion  is 
sufficient  for  all  of  the  needs  of  the  body,  for  this  reason  diseases 
of  the  ductless  glands  do  not  usually  produce  characteristic  symp- 
toms until  the  gland  itself  is  almost  completely  destroyed. 


DISEASES  OF  THE  THYROID  GLAND 

The  thyroid  gland  is  one  of  an  important  series  of  organs 
which  elaborate  an  internal  secretion.  The  relation  between  the 
pathological  changes  in  the  thyroid  gland  and  the  symptoms  of 
the   diseases   associated   with   these  pathological   changes   is   yet 

294 


THYROIDITIS  295 

somewhat  uncertain.  Whether  the  thyroid  changes  are  causes  of 
the  other  symptoms,  or  whether  they  are  due  to  some  other  etio- 
logical factor  which  also  causes  the  symptoms  observed,  is  as  yet 
uncertain.  There  seems  no  question  that  to  a  certain  extent  at 
least,  the  symptoms  of  some  diseases  of  the  thyroid  gland  are 
directly  referable  to  variations  in  the  secretions  of  the  gland  itself. 
Very  much  yet  remains  to  be  cleared  away  before  our  under- 
standing of  any  of  the  internal  secretions  is  satisfactory.  The  pres- 
ence of  accessory  thyroid  masses  adds  complicating  factors. 

The  thyroid  gland  is  extremely  vascular  and  it  is  normally 
subject  to  marked  variations  in  its  blood  supply.  The  blood  ves- 
sels are  controlled  by  vasomotor  nerves  from  the  superior,  middle 
and  inferior  cervical  sympathetic  ganglia.  These  ganglia  are  in 
turn  controlled  by  way  of  the  white  rami,  which  originate  in  the 
first  or  second  to  the  fourth  or  fifth  spinal  segments.  Irritating 
conditions  of  the  thyroid  cause  reflex  muscular  contractions  and 
areas  of  hypersensitiveness  through  the  upper  cervical  areas  and 
the  upper  thoracic.  The  tissues  around  the  clavicles  and  first  ribs 
are  always  hypersensitive.  The  scaleni  and  certain  others  of  the 
anterior  cervical  muscles  are  usually  contracted. 

The  third  cervical  vertebra  is  practically  always  Included  in  the 
bony  lesions  present  in  all  forms  of  goiter.  Lesions  of  other  cervi- 
cal vertebrae,  the  clavicles,  the  first  and  second  ribs,  and  the  man- 
dible are  present  in  varying  combinations.  These  bony  mal-posi- 
tions  probably  act  by  modifying  the  circulation  through  the  thyroid 
gland,  and  possibly  by  interfering  with  the  normal  secretory  or 
trophic  nerve  impulses.  The  correction  of  these  lesions  usually 
exerts  at  least  a  slight  effect  upon  the  goiter,  and  under  favorable 
circumstances,  results  in  a  return  to  approximately  normal  con- 
ditions. 

ACUTE  THYROIDITIS 

This  is  an  acute  inflammation  of  the  thyroid  gland,  whether 
the  gland  is  or  is  not  normal  before  the  onset.  The  term  "strum- 
itis" is  limited  to  the  inflammation  of  a  previously  diseased  or 
goitrous  thyroid.  The  usual  phenomena  of  inflamed  glandular 
tissue — swellings,  dilated  blood  vessels,  sometimes  hemorrhages 
and  accumulations  of  pus — are  present.  It  is  almost  always  sec- 
ondary to  acute  infectious  diseases,  or  to  septic  surgery,  or  to 
trauma. 

The  diagnosis  is  to  be  made  by  the  severe  symptoms,  the  recog- 
nition of  the  causative  factors,  and  the  history  of  the  case.  Con- 
gestion, such  as  occurs  at  the  menstrual  period,  is  not  to  be  included 
as  an  inflammation  of  the  gland.  The  symptoms  include  swelling, 
dyspnea  and  other  pressure  symptoms,  cyanosis,  epistaxis,  some- 
times hemorrhages,  usually  fever,  and  sometimes  rapid,  irregular, 


296  THE  THYROID 

or  slow  heart  from  pressure  on  the  vagus,  with  its  palpitating 
carotid  neighbor. 

The  treatment  includes  correction  of  the  muscular  contractions 
and  of  whatever  other  structural  causes  of  thyroid  congestion  may 
be  found;  raising  the  ribs,  increasing  the  flexibility  of  the  lower 
thoracic  spinal  column,  and  such  other  measures  as  may  be  indi- 
cated on  examination.  No  food  is  to  be  taken  during  the  active 
stage;  water,  ice  and  fruit  juices  much  diluted  may  be  allowed. 
Pus  should  be  surgically  evacuated.  If  the  pressure  causes  symp- 
toms of  asphyxia,  intubation  or  tracheotomy  may  be  necessary — 
the  danger  of  infection  in  such  cases  must  be  clearly  remembered. 

Prognosis.  The  evacuation  of  the  pus,  either  spontaneously  or 
surgically,  or  the  absorption  of  the  products  of  inflammation,  with- 
out evacuation,  may  result  in  recovery,  with  the  formation  of  scar 
tissue  which  may  or  may  not  be  of  later  significance.  The  pus 
may  evacuate  into  the  trachea,  leading  to  fatal  pulmonary  dis- 
ease; or  into  the  tissues  of  the  neck,  leading  to  cellulitis,  perhaps 
with  abscesses  later.  The  pressure  may  cause  death  from  asphyxia. 
After  apparent  recovery,  the  symptoms  of  myxedema  may  occur, 
due  to  the  destruction  of  the  secreting  tissue  of  the  gland. 

SIMPLE  GOITER 

Enlargement  of  the  thyroid  gland  not  associated  with  symp- 
toms of  hyperthyroidism  is  called  simple  goiter.  The  enlargement 
may  be  due  to  increase  in  its  connective  tissues ;  to  dilation  of  the 
blood  vessels  or  the  lymph  spaces ;  or  to  increase  in  the  amount  of 
colloidal  material  within  the  cysts,  or  to  other  less  common  patho- 
logical changes  in  the  gland.  Simple  goiter  may  attain  tremendous 
size  without  seriously  impairing  the  health  of  the  patient.  In 
other  cases,  the  growth  exerts  pressure  upon  the  nerves  of  the 
neck  or,  extending  downward,  may  diminish  the  size  of  the  tho- 
racic inlet. 

Etiology.  The  disease  is  sometimes  endemic.  Change  of  cli- 
mate frequently  improves  the  condition  in  these  cases.  Heredity 
is  a  factor  in  many  cases.  The  children  of  goitrous  parents  may 
be  cretins,  or  may  be  normal,  or  may  themselves  suffer  from  goiter 
later  in  life.  The  relation  of  goiter  to  sexual  disturbances  is  well 
marked.  In  men  goiter  may  increase  after  sexual  excess.  In 
women  the  gland  frequently  enlarges  in  menstruation  and  preg- 
nancy, while  it  is  practically  normal  in  the  intervals.  Emotional 
disturbances  may  initiate  or  exacerbate  the  thyroid  enlargement, 
Ernest  Sisson  calls  attention  to  the  place  of  the  third  cervical 
lesion  in  goiter  and  also  to  the  overuse  of  the  voice  as  in  voice, 
training  as  a  cause  of  goiter.  C.  P.  McConnell's  experiments  show 
the  place  of  the  third  cervical  lesions  in  the  etiology  of  simple 


EXOPHTHALMIC  GOITER  297 

goiter.  The  upper  thoracic,  first  rib,  clavicle,  hyoid,  atlas,  axis 
and  other  cervical  vertebrae  are  reported  by  other  writers  as 
being  etiological  in  simple  goiter. 

Diagnosis.  The  enlargement  of  the  gland  is  easily  recogniz- 
able. When  the  tumor  is  small,  or  when  its  growth  invades  the 
cervical  tissues  causing  pressure  upon  the  vagus  and  sympathetic 
nerves,  or  upon  the  jugular  vein  and  carotid  artery,  or  upon  the 
trachea,  the  symptoms  may  be  very  much  confused.  Irregular 
heart  beat,  sometimes  rapid ;  dilation  of  the  pupils  with  mild  exoph- 
thalmos ;  giddiness,  vertigo,  nausea  and  more  or  less  marked  men- 
tal symptoms  due  to  abnormal  pressure  conditions  may  suggest 
exophthalmic  goiter.  The  fact  that  simple  goiter  may  occasionally 
take  on  the  exophthalmic  type  adds  difficulty  to  the  diagnosis. 
More  frequently  degeneration  occurs  in  the  simple  goiter,  leading 
to  symptoms  of  myxedema;  usually  the  simple  goiter  remains 
unchanged  in  character  throughout  life. 

As  the  simple  goiter  increases  in  size  its  weight  may  cause 
considerable  discomfort.  The  pressure  exerted  upon  the  trachea 
may  lead  to  asphyxia.  Small  goiters  are  not  incompatible  with 
long  and  comfortable  living. 

Treatment.  The  correction  of  the  bony  lesions  already  men- 
tioned is  sometimes  the  only  treatment  that  is  necessary.  Usually 
several  weeks  or  months  of  attention  is  necessary  in  order  to 
prevent  recurrence.  The  upper  ribs  should  be  raised  and  the 
clavicles  lifted;  the  cervical  tissues  well  relaxed;  the  hyoid  moved 
from  side  to  side  and  attention  paid  to  all  tissues  which  might 
possibly  interfere  with  the  normal  drainage  of  the  gland.  Undue 
pressure  or  manipulation  of  the  gland  may  cause  symptoms  of 
hyperthyroidism.  This  was  often  noted  in  the  old-time  treat- 
ment by  bandaging  the  neck.  Tissues  around  the  gland  may  be 
lifted  and  pushed  toward  the  gland  in  order  to  permit  free  exit 
of  blood  and  lymph  from  that  neighborhood.  (R.  D.  Emery.) 
The  patient  should  not  overuse  the  voice  and  should  be  warned 
against  sexual  indulgence.     (E.  Sisson.) 

Prognosis.  Circulatory  goiters  may  diminish  with  remarkable 
speed.  Cystic  goiters  become  smaller  but  rarely  regain  normal 
size  unless  the  condition  is  of  very  recent  development.  Fibroid 
goiters  (and  those  which  have  existed  for  several  years  usually 
are  more  or  less  fibroid)  rarely  regain  normal  size,  if  indeed  they 
ever  do.  They  may  be  diminished  and  may  cause  no  further 
symptoms. 

EXOPHTHALMIC  GOITER 

(Basedow's  disease;  Graves'  disease;  hyperthyroidism;  hyperplastic  gofter) 
Enlargement  of  the  thyroid  gland,  with  protruding  eye-balls, 
muscular  tremor,   and   rapid  heart  make  up   a   syndrome  called 


298  THE  THYROID 

exophthalmic  goiter.  The  thyroid  enlargement  is  never  very 
great;  the  exophthalmos  may  be  delayed  until  after  the  other 
symptoms  have  been  some  time  present. 

Pathology.  The  structural  changes  are  not  well  understood.  A  true 
hypertrophy  of  the  gland  has  been  described ;  increased  vascularization  is  con- 
stant. The  superior  and  middle  cervical  sympathetic  ganglia  have  been  found 
more  or  less  degenerated.  The  pathogenesis  of  the  disease  has  been  much 
discussed ;  the  relationship  between  this  disease  and  myxedema  and  cretinism 
is  of  interest. 

Other  tissues  and  organs  of  the  body  are  abnormal  in  this  disease;  the 
adrenals,  pituitary  body,  pancreas,  thymus  and  para-thyroids  are  variously 
atrophied  or  inflamed  when  the  thyroids  are  hypertrophied.  Sugar-metabolism 
is  often  perverted,  though  rarely  to  the  point  of  typical  diabetes  mellitus ; 
pol3airia  without  glycosuria  occurs.  The  pigmentation  of  the  skin,  with  or 
without  scleroderma  or  leucoderma,  is  of  interest  in  this  connection ;  the 
bronzing  of  Addison's  is  not  often  present.  A  fatty  cushion  behind  the  eyeball 
is  the  result,  rather  than  the  cause,  of  the  exophthalmos.  F.  J.  Feidler  and 
others  view  exophthalmic  goiter  as  a  systemic  disease,  in  which  hyperthyroidism 
is  a  symptom  rather  than  a  cause.  Most  of  the  evidence  is  in  favor  of  hyper- 
thyroidism as  a  cause  of  the  other  symptoms  as  observed,  though  the  ultimate 
cause  of  the  increased  thyroid  activity  is  yet  to  be  found. 

Etiology.  Occasionally  a  simple  goiter  assumes  the  character- 
istic features  of  the  exophthalmic  type.  Emotional  storms  have 
often  been  mentioned,  by  the  patient  or  his  family,  as  the  cause 
of  the  disease ;  it  is  difficult  to  determine  whether  the  emotionalism 
w^as  a  cause,  or  was  simply  one  of  the  earlier  symptoms  of  the 
disease;  the  causes  of  the  emotionalism  are  usually  found  to  be 
comparatively  mild,  such  as  are  "the  common  fate  of  all"  and 
which  are  not  associated  with  any  permanent  after-eflfects  in  most 
individuals.  Pregnancy  and  lactation,  exhausting  diseases,  and 
other  factors  which  certainly  lower  the  general  bodily  resistance 
to  disease  are  considered  causative  factors  in  many  cases.  Foci 
of  infection  of  the  upper  respiratory  tract  and  mouth,  and  intes- 
tinal stasis  are  possible  factors. 

Lesions  of  the  first  to  sixth  thoracic  are  most  important ; 
lesions  of  the  cervical  vertebrae,  the  first,  second  and  third  ribs, 
of  the  occiput,  hyoid,  mandible,  and  clavicle,  are  reported. 

Diagnosis.  In  well-developed  cases,  the  protruding  eye-balls, 
nervous  instability,  rapid  pulse,  muscular  tremor,  and  slightly 
enlarged  thyroid,  make  the  diagnosis  easy.  In  the  early  stages, 
diagnosis  may  be  somewhat  difficult.  Wasting  may  be  a  very 
early  symptom ;  when  this  is  associated  with  muscular  tremor 
hyperthyroidism  should  be  suspected.  When  to  these  symptoms 
the  rapid  heart  is  added,  with  nervous  instability,  the  diagnosis  is 
fairly  certain ;  exophthalmos  removes  doubt,  even  if  the  enlarge- 
ment of  the  gland  is  not  yet  perceptible. 

The  onset  is  usually  insidious,  though  occasionally  the  disease 
may  develop  rapidly,  even  to  death  within  a  few  days  or  weeks. 
In  these  acute  cases  diarrhea  and  vomiting  are  associated  with 


EXOPHTHALMIC  GOITER  299 

extremely  rapid  pulse,  dyspnea,  and  speedy  emaciation.  In  chronic 
cases  the  heart  may  beat  at  100  or  more,  rarely  to  200,  The  thyroid 
pulsation  is  constant ;  a  peculiar  rushing  sound  is  frequently  heard 
over  the  gland.  The  heart  may  be  enlarged ;  hemic  murmurs  may 
be  present. 

Diarrhea  and  vomiting  may  or  may  not  be  present.  The  appe- 
tite is  whimsical.  The  secretion  of  sweat  is  usually  increased; 
sometimes  this  affects  the  hands  or  feet  especially ;  rarely  one  side 
of  the  body  is  most  affected  by  the  hyperidrosis.  Night  sweats  are 
common.  Flushings  and  pallor  may  occur  without  recognizable 
cause ;  these  often  resemble  the  "hot  flashes"  of  the  menopause. 
Discolorations  and  thickenings  of  the  skin  may  suggest  Addison's 
disease,  pregnancy,  scleroderma,  and  other  trophic  disturbances 
of  the  skin. 

The  eye  symptoms  are  marked ;  the  protrusion  of  the  eye-balls 
may  become  so  pronounced  that  closure  is  impossible.  The  upper 
lid  does  not  follow  the  eye-ball  when  the  gaze  is  directed  down- 
ward— von  Graefe's  sign.  Retraction  of  the  upper  lid  causes  widen- 
ing of  the  palpebral  fissure — Stellwag's  sign.  Imperfect  converg- 
ence for  very  close  vision — Moebius'  sign — may  be  present  also  in 
myopia,  hysteria  and  neurasthenic  states.  Rarely  paralysis  of  the 
external  eye  muscles  is  observed.  Tremor  of  the  muscles  of 
the  eye-ball  and  of  the  lids  is  frequent.  The  exophthalmos  appears 
to  be  due  to  the  contraction  of  the  nonstriated  muscle  fibers  of  the 
capsule  of  Tenon;  the  symptoms  referable  to  the  upper  lid  are 
probably  due  to  action  of  the  non-striated  fibers  of  the  levator 
palpebrse;  both  these  muscles  are  controlled  by  the  sympathetic 
nerves. 

The  nervous  symptoms  are  conspicuous.  The  muscular  tremor 
is  fine — about  8  per  second.  Muscular  tone  is  increased.  Psychic 
changes  are  marked.  The  mental  instability  rarely  reaches  the 
point  of  actual  insanity,  but  may  resemble  mania  or  delirium  tem- 
porarily. Most  often  irritability  with  rapid  and  exaggerated  ten- 
dency to  be  affected  by  trifles  is  the  most  conspicious  factor  in 
the  mentality.  This  is  responsible  for  the  erratic  way  in  which 
such  patients  change  physicians  and  methods  of  treatment — they 
are  often  very  unsatisfactory  patients,  disobedient  and  refractory. 

The  urine  may  show  increased  nitrogen  elimination;  it  is  diffi- 
cult to  keep  these  patients  in  N-equilibrium.  Increased  excretion 
of  phosphorus  is  present  in  some  cases.  The  blood  is  normal  in 
hemoglobin  and  erythrocyte  count ;  the  lymphocytes  are  often 
greatly  increased  while  the  neutrophiles  are  diminished.  The  vis- 
cidity is  increased;  the  coagulation  time  is  usually  increased. 

Treatment.  The  treatment  of  exophthalmic  goiter  includes 
those  measures  already  advised  for  simple  goiter,  and  attention 
to  the  factors  in  etiology,  plus  an  increased  amount  of  rest,  the 


300  THE  THYROID 

avoidance  of  all  excitement,  worry,  or  overstrain  of  any  kind  and 
a  largely  vegetable  diet.  These  patients  seem  to  have  a  peculiar 
inability  to  dispose  of  the  waste  products  formed  by  a  meat  diet. 
Correction  of  the  bony  lesions  as  found  has  resulted  in  apparently 
permanent  recovery  in  many  cases.  Rest  in  bed  for  a  few  days, 
at  intervals  of  a  few  weeks,  is  useful  in  cases  with  marked  heart- 
hurry.  The  ice  bag  over  the  heart  gives  relief  in  exacerbations  of 
tachycardia.  Change  of  climate  is  useful  in  some  cases,  especially 
from  a  goitrous  region  to  higher  altitude — not  best  above  4,000 
feet.  Sea  level  relieves  the  dyspnea  and  heart-hurry  in  certain 
cases — individuals  vary  in  susceptibility  to  climatic  conditions. 

The  preferred  operative  treatment  consists  of  consecutive  liga- 
tions of  the  thyroid  arteries — one  is  tied,  and  the  effects  noted, 
then  another,  until  normal  activity  of  the  gland  is  secured.  Partial 
thyroidectomy  sometimes  gives  good  results.  Injection  of  boiling 
water  into  the  gland  destroys  a  part  of  the  glandular  tissue,  and 
this  may  result  in  toxic  symptoms,  not  usually  very  serious.  It  is 
employed  only  in  mild  or  early  cases.  In  a  few  cases  operation 
on  the  thymus  seems  necessary. 

In  acute  forms,  and  during  exacerbations  of  the  chronic  forms, 
operations  are  apt  to  be  fatal.  In  any  case,  injury  or  destruction  of 
a  part  of  the  gland  may  result  in  atrophy  of  the  rest  of  the  gland ; 
the  symptoms  of  myxedema  may  appear,  or  death  may  occur  too 
rapidly  for  these  symptoms  to  become  noticeably  developed. 

It  is  necessary  to  recall  that  secretory,  trophic  and  vasomotor 
nerves  arise  from  the  upper  dorsal,  and,  though  cervical  lesions  are 
important,  the  effect  is  probably  due  to  the  contiguous  structural 
relationship  of  the  sympathetics.  Then,  there  is  a  distinct  rela- 
tionship between  the  adrenal  secretion  and  thyroid  activities. 

D.  L.  Tasker  reports  a  case  with  third  cervical  and  seventh 
to  tenth  thoracic  lesions,  in  which  treatment  for  correction  was 
not  successful  so  far  as  the  bones  were  concerned,  but  was  fol- 
lowed by  relief  of  symptoms,  with  increased  mobility  and  lessened 
tension  of  the  tissues. 

Prognosis.  This  is  always  grave.  Death  may  occur  in  a  few 
weeks,  in  the  acute  cases — rarely  in  a  few  days.  In  the  more  fre- 
quent chronic  cases,  death  may  be  postponed  for  months,  rarely 
years,  unless  a  remission  occurs — as  is  not  infrequent.  With  treat- 
ment of  the  structural  conditions,  recovery  may  be  apparently  com- 
plete; some  cases  have  been  watched  for  several  years  with  no 
recurrence  of  the  disease. 

MYXEDEMA  AND  CRETINISM 

Myxedema  is  a  condition  of  perverted  body  metabolism  asso- 
ciated with  disturbances  in  the  secretion  of  the  thyroid  gland  and 
probably  due  to  the  lack  of  this  secretion. 


MYXEDEMA  301 

Three  forms  are  recognized.  In  the  congenital  form  the  thyroid 
gland  is  absent  or  is  functionally  inefficient  from  birth.  Children 
so  affected  are  called  cretins.  Operative  myxedema  or  cachexia 
strumipriva  is  due  to  the  surgical  or  accidental  destruction  of  the 
thyroid  gland.  Atrophic  myxedema  is  due  to  the  degeneration  or 
atrophy  of  the  thyroid  and  it  may  follow  goiter. 

Cretinism.  Cretins  are  usually  idiots ;  they  appear  fairly  normal 
at  birth,  but  they  fail  to  develop  as  normal  children  should.  They 
are  often  unable  to  support  the  head  until  long  past  the  time 
when  they  should  be  sitting  alone.  Sometimes  the  condition  does 
not  become  manifest  until  the  child  is  able  to  walk.  The  position 
of  the  body  is  characteristic — the  child  stands  with  the  feet  apart, 
often  with  the  knees  bent  together ;  the  abdomen  is  very  protuber- 
ant ;  there  is  marked  lumbar  kyphosis,  which  adds  to  the  apparent 
size  of  the  pendulous  abdomen;  the  mouth  usually  hangs  open. 
The  muscles  of  the  body  are  deficient  in  tone.  The  child  appears 
fat,  but  this  appearance  is  due  to  a  hardened  and  slightly  edema- 
tous condition  of  the  skin ;  pitting  does  not  occur  on  pressure.  The 
growth  of  the  skeleton  is  greatly  delayed — at  the  age  of  twenty 
the  cretin  may  not  be  more  than  forty  inches  tall.  The  face,  arms 
and  legs  are  abnormally  broad.  Mental  development  ceases  at  an 
early  stage ;  the  child  may  never  learn  to  talk.  The  blood  pressure 
is  low,  the  heart's  action  slow,  but  not  correspondingly  strong. 
The  fact  that  the  condition  is,  in  part,  due  to  the  lack  of  the  thyroid 
secretion  is  indicated  by  the  improvement  which  occurs  upon  the 
administration  of  thyroid  extract. 

Etiology.  Cretinism  appears  to  be  hereditary.  In  some  cases 
there  are  families  in  whom  cretins  occur  in  every  generation.  No 
direct  inheritance  is  possible.  Parents  who  have  goiter  often  have 
children  who  are  cretins.  The  disease  may  appear,  very  rarely, 
sporadically.  Malaria  and  syphilis  in  the  parents  is  supposed  to 
be  responsible  for  some  cases.  In  one  Pacific  College  Clinic  case, 
it  was  not  possible  to  find  anything  in  either  parent,  or  anywhere 
in  the  family,  which  could  have  been  responsible  for  the  condition 
of  the  child.  In  other  cases,  paternal  syphilis,  maternal  goiter,  or 
family  inheritance  were  found  present. 

Treatment.  The  symptoms  of  cretinism  do  not  occur  in  a 
typical  manner  when  any  part  of  the  functional  thyroid  gland 
remains.  Definite  permanent  improvement  has  been  noted  follow- 
ing adjustment  of  upper  dorsal  and  cervical  lesions,  even  when 
the  use  of  extract  has  failed.  Any  method  of  treatment  may 
include  the  administration  of  the  thyroid  gland  of  animals,  or  the 
use  of  extracts  from  these.  The  commercial  extracts  should  be 
administered  first,  and  it  is  necessary  to  give  very  small  doses  in 
the  beginning,  increasing  these  until  the  physiological  effects  are 


302  THB  THYROID 

observed.  Different  preparations  of  thyroid  contain  varying 
amounts  of  different  products  of  thyroid  metabolism.  If  one  prep- 
aration causes  unpleasant  symptoms,  or  if  it  seems  to  be  inefficient 
in  modifying  the  symptoms  of  cretinism,  another  should  be  tried. 
If  none  of  the  ordinary  preparations  on  the  market  modify  the 
course  of  the  disease,  the  thyroid  itself  may  be  fed.  In  order  to 
receive  the  best  results,  the  fresh  thyroid  should  be  ordered.  It 
may  be  sliced  and  slightly  cooked  upon  its  outer  surface.  The 
equivalent  of  one  thyroid  should  be  eaten  once  to  three  times  each 
w^eek.  This  mtethod  is  not  very  accurate,  but  it  sometimes  brings 
about  improvement  in  the  condition  when  the  more  convenient 
methods  of  administration  have  failed.  Overfeeding  of  thyroid 
extract  may  cause  rapid  heart  beat,  dyspnea,  nervous  instability, 
diarrhea,  nausea,  headache,  and  sometimes  other  symptoms.  The 
amount  of  thyroid  should  be  cut  down  in  such  cases.  It  must  be 
remembered  also  that  whatever  conditions  have  been  responsible 
for  the  lack  of  the  thyroid  may  have  affected,  also,  other  organs. 

Prognosis.  It  is  not  to  be  expected  that  the  cretin  will  ever 
occupy  the  place  in  life  to. which  he  might,  otherwise,  be  entitled. 
By  the  artificial  administration  of  the  thyroid  extract,  which  the 
body  needs,  life  may  be  made  much  more  comfortable  and  efficient. 
In  those  cases  in  which  the  thyroid  of  the  patient  becomes  active, 
the  prognosis  is  brighter  for  fairly  normal  mental  development. 

Operative  Myxedema  is  now  of  infrequent  occurrence.  It  fol- 
lows total  extirpation  of  the  thyroid,  or  the  degeneration  of  parts 
of  the  gland  that  might  be  left  after  operation  for  goiter.  It  is 
characterized  by  low  blood  pressure,  increased  breadth  of  the  face, 
hands  and  feet,  with  marked  thickening  and  hardening  of  the  skin. 
The  edematous  areas  do  not  pit  on  pressure,  nor  do  they  contain 
fluid.  The  mental  processes  become  steadily  deficient,  resulting  in 
dementia  if  death  does  not  occur  at  an  early  time.  The  progress 
of  the  disease  may  be  delayed  by  the  use  of  animal  extracts,  as  in 
cretinism.  The  cause  of  the  original  disease  for  which  the  opera- 
tion was  necessary  should  be  studied,  and  that  condition  also 
should  receive  attention.  Structural  perversions  should  be  cor- 
rected and  symptomatic  treatment  instituted  when  necessary;  the 
use  of  the  animal  extracts  alone  may  not  m.eet  all  the  individual 
requirements  of  the  case. 

Atrophic  Myxedema.  This  may  appear  as  a  primary  disease, 
or  may  result  from  degenerative  processes  following  goiter.  The 
symptoms  are  those  of  the  operative  type,  except  that  the  onset  is 
more  gradual,  and  is  often  confused  by  some  of  the  symptoms  of 
hyperthyroidism.  The  mental  state  is  frequently  confused ;  the 
patient  is  at  times  erratic  and  penetrating,  at  others  stupid  and 
indolent;  confusional  symptoms  are  usually  present  in  either  case, 


PARATHYROIDS  303 

and  dementia  finally  results.  The  treatment  consists  in  first,  an 
attempt  to  restore  normal  function  to  the  gland  by  correcting  the 
conditions  which  interfere  with  its  circulation,  drainage,  innerva- 
tion, and  after  this  has  failed,  the  administration  of  the  animal 
extracts,  or  of  the  fresh  gland.  If  one  extract  does  not  meet  the 
requirements,  other  preparations  should  be  tried;  the  use  of  the 
fresh  gland  is  inconvenient  and  often  of  no  value  but  is  sometimes 
more  efficient  than  the  prepared  extracts.  Hypodermic  prepara- 
tions may  be  more  useful  than  those  given  by  mouth,  or  vice  versa. 


DISEASES  OF  THE  PARATHYROIDS 

These  small  ductless  glands'  lie  in  the  neck  and  their  position 
is  decidedly  variable.  One  disease,  tetany,  is  supposed  to  be  due 
to  lesion  of  the  parathyroids.  It  seems  probable  that  certain  con- 
vulsive disturbances,  sometimes  mistaken  for  hysteria,  are  really 
due  to  the  lack  of  secretion  or  to  the  abnormal  secretion  of  these 
small  glands.  y 

Etiology.  Perhaps  the  most  common  cause  of  parathyroid 
injury  is  that  due  to  the  injury  or  removal  of  these  in  thyroid 
operations.  Other  causes  are  the  infectious  diseases,  extension  of 
inflammation  from  neighboring  tissues,  and  rarely  a  primary  inter- 
stitial inflammation  without  recognizable  cause. 

Tetany  is  a  disease  of  the  body  which  is  characterized  clin- 
ically by  variations  in  the  muscular  tone,  and  disturbances  of  motor 
control.  During  the  intervals  between  the  attacks,  the  patient 
appears  to  be  fairly  well,  except  for  the  existence  of  areas  of 
extreme  hypersensitiveness  in  various  parts  of  the  body.  The 
hands,  feet,  and  face  appear  to  be  swollen  or  edematous,  but  do  not 
pit  on  pressure.  There  is  a  tendency  for  the  skin  to  be  somewhat 
purplish.  Pressure  over  the  nerve  trunks,  or  over  large  vessels 
which  lie  near  nerve  trunks,  may  produce  an  attack  at  almost  any 
time.  The  attacks  may  vary  from  a  few  minutes  to  several  hours, 
or  sometimes  several  days.  At  first  there  appears  a  peculiar  sen- 
.sory  disturbance,  as  numbness^  tingling,  or  other  parasthesias. 
The  muscles,  usually  first  of  the  fingers,  seem  to  stiffen  and  this 
condition  gradually  extends  to  the  arms,  trunk  and  finally  to  the 
entire  body.  The  spasmodic  cramps  are  not  especially  painful 
when  the  muscular  contraction  is  feeble ;  the  greater  the  amount 
of  contraction,  the  greater  the  pain  in  the  affected  muscles. 
Attacks  may  be  nocturnal  only,  or  may  occur  at  varying  intervals. 
An  attack  may  be  precipitated  at  any  time  by  violent  emotional 
storms,  or  by  any  strenuous  effort  (Trousseau's  sign). 

Slight  fever  may  occur  during  the  attack.  The  urine  is  espe- 
cially rich  in  the  phosphates  and  the  calcium  salts. 


304  THE  DUCTLESS  GLANDS 

The  prognosis  for  recovery  is  gloomy.  There  may  be  an 
interim  in  the  progress  of  the  disease.  Death  may  occur  at  any 
time  within  a  very  few  days  from  the  development  of  the  disease 
from  cachexia,  respiratory  failure,  or  the  effect  produced  in  the 
central  nervous  system  by  the  poisons  in  the  circulating  blood. 

Treatment.  The  treatment  must  be  symptomatic.  It  may  be 
necessary  to  use  chloroform  for  the  relief  of  the  spasms.  The  gen- 
eral health  of  the  patient  should  be  improved.  Occasionally  the 
administration  of  thyroid  extract,  either  with  or  without  para- 
thyroid extract,  results  in  recovery. 


DISEASES  OF  THE  PITUITARY  BODY 

Diseases  of  the  pituitary  body  may  affect  either  its  anterior  or 
its  posterior  lobe  or  both.  The  symptoms  produced  vary  accord- 
ingly and  may  be  confused  by  the  effects  of  pressure  upon  the  optic 
nerves  and  neighboring  tissues  and  in  the  case  of  tumor  of  the 
pituitary  by  the  effects  of  increased  intracranial  pressure. 

Overfunction  of  the  anterior  lobe  (hyperhypophysism,  hyper- 
pituitarism), gives  rise  to  acromegaly  or  gigantism,  with  various 
modifications  of  these.  Overfunction  of  the  posterior  lobe  or  the 
pars  intermedia  causes  symptoms  of  diabetes  insipidus.  Under- 
f unction  of  the  anterior  lobe  (hypohypohysism,  hypopituitarism), 
gives  rise  to  the  symptom  complex  included  under  "Frohlich's 
type,"  (hypophyseal  dystrophia  adiposogenitalis),  characterized 
by  rapid  obesity,  infantilism  of  the  genitals,  myxedema-like  skin. 
This  state  is  sometimes  associated  with  dwarfism,  pseudoherma- 
phroditism, asthenic  states,  tachycardia,  bronzing,  and  other  symp- 
toms referable  to  various  endocrine  disturbances. 

In  all  diseases  of  the  pituitary  body  X-ray  plates  may  show 
peculiarities  of  the  sella  turcica. 

Acromegaly.  This  is  a  rare  disease  most  often  associated  with 
tumor  of  the  pituitary  body,  characterized  by  gradual  deformity 
of  the  face,  hands,  feet  and  to  a  less  marked  extent  other  bones 
of  the  body.  The  face  shows  broadening  and  prognathism;  the 
malar  bones  increase  in  size  until  they  may  resemble  horns.  The 
bones  of  the  fingers,  hands  and  feet  broaden  very  conspicuously. 
The  skin  becomes  hard  and  thick.  The  hair  thins  and  falls.  The 
nails  become  very  broad,  thick  and  heavy.  Mentality  slowly 
diminishes  in  vigor  to  complete  dementia.  Blindness,  either  par- 
tial or  complete,  is  usually  due  to  pressure  upon  the  optic  nerves 
or  the  optic  tracts. 

Giantism.  Disease  of  the  pituitary  body  occurring  before  or 
shortly  after  birth  may  result  in  symmetrical  enlargement  of  the 
bones  so  that  the  child  becomes  abnormally  large  without  being 


THE  PITUITARY  BODY  305 

especially  deformed.    These  giants  may  attain  a  height  of  seven  or 
eight  feet.    They  are  weak  in  body  and  mind. 

Dwarfism.  Deficient  development  of  the  long  bones  or  of  all 
of  the  bones  of  the  body  may  be  due  to  pituitary  disease.  In  both 
giantism  and  dwarfism,  hereditary  syphilis  may  be  a  factor. 

Osteitis  Deformans.  This  disease  may  not  be  due  to  pituitary 
involvement,  but  the  symptoms  suggest  very  strongly  such  a  rela- 
tionship. 

The  name  is  also  applied  to  a  very  different  condition — in 
which  single  bones  are  affected  through  repeated  irritation,  as  in 
men  who  are  much  on  horseback,  and  may  suffer  from  deforming 
osteitis  of  the  femyr.  In  such  cases  disease  of  the  pituitary  body 
is  not  probable. 

In  its  systemic  form  osteitis  deformans  affects  nearly  all 
of  the  bones  of  the  body.  It  appears  in  middle  life,  chiefly  among 
males,  and  is  not  due  to  any  recognizable  antecedent  disease.  The 
skull  thickens  and  increases  in  size  so  that  the  circumference  of 
the  head  may  be  two  inches  or  more  above  normal.  The  bones 
of  the  arms  and  legs  are  greatly  thickened  and  softened.  They 
are  bowed  anteriorly  and  laterally  producing  a  characteristic  wad- 
dling gait  and  position  of  the  arms.  The  subcutaneous  knife  edge 
of  the  shin  may  become  broadened  to  two  inches  or  more.  The 
X-ray  of  the  bones  shows  them  much  broader  and  much  less  dense 
than  normal.  During  the  stage  of  active  inflammation  circular 
areas  of  diminished  density  cause  the  X-ray  plate  to  display  a 
peculiar  "bubbly"  appearance. 

The  stage  of  active  inflammation  is  associated  with  dull,  aching 
pain  of  a  peculiarly  unbearable  type.  The  muscles  attached  to  the 
affected  bones  and  the  skin  over  them  are  hypersensitive  and  the 
seat  of  considerable  pain.  The  mental  attitude  of  the  patient  is 
characterized  by  profound  gloom,  not  like  melancholia  nor  with 
any  evidences  of  true  insanity,  but  simply  a  distressing  depression 
of  spirits,  which  is  most  unendurable  to  the  patient  himself  and 
to  his  friends. 

In  one  P,  C.  O.  clinic  case,  palliative  treatment,  devoted  to 
securing  relief  from  reflex  muscular  contractions,  was  moderately 
successful  in  relieving  pain  during  exacerbations. 

Hypophysis  Adiposity.  Disease  of  the  pituitary  body  some- 
times manifests  itself  as  a  loss  of  control  of  fatty  growth.  These 
cases  occur  in  childhood  or  puberty  and  are  characterized  by  a 
remarkable  and  uncontrollable  obesity.  Such  children  retain  health 
and  strength  for  months  or  even  a  few  years  after  the  obesity 
becomes  pronounced.  With  the  development  of  the  sexual  organs 
and  other  ductless  glands  at  puberty  the  adiposity  may  slowly 
disappear  and  the  patient  retain  good  health  for  the  rest  of  his 


306  THE  DUCTLESS  GLANDS 

life.  In  other  cases,  probably  those  in  which  there  is  a  structural 
disorganization  of  the  pituitary  body,  the  symptoms  of  brain 
tumor  appear,  usually  followed  by  death.  In  all  these  cases  of 
adiposity  the  bones  seem  rather  more  easily  broken  than  is  normal. 
The  fatty  overgrowth  interferes  with  the  recognition  of  the  frac- 
ture so  that  permanent  deformity,  especially  of  the  hip  joint,  may 
be  produced  by  neglect  due  to  imperfect  diagnosis.  In  one  patient 
examined  in  the  P.  C.  O.  clinic  fracture  of  the  surgical  neck  of  the 
femur  was  found  which  had  been  overlooked  for  some  months. 

Treatment  and  Prognosis.  Disease  of  the  pituitary  body,  like 
that  of  other  ductless  glands,  is  not  apt  to  manifest  itself  until  the 
internal  secretion  is  almost  or  quite  totally  absent.  For  this  reason 
there  is  very  little  that  can  be  done  in  the  way  of  treatment.  Com- 
pensatory activity  on  the  part  of  other  glands  appears  to  occur 
when  the  pituitary  body  is  involved  to  a  greater  extent  than  is 
the  case  with  other  ductless  glands.  The  use  of  the  animal  extracts 
in  the  diseases  characterized  by  bone  changes  has  not  been  suc- 
cessful. In  adiposity  the  use  of  pituitrin  has  been  followed  by 
good  results. 

The  possibility  of  surgery  should  be  considered.  Since  the 
prognosis  is  hopeless  when  the  pituitary  fossa  is  invaded  by  malig-* 
nant  tumor,  surgical  interference  even  with  its  very  doubtful  prog- 
nosis may  be  justified.  Recovery  is  never  to  be  expected  in  pitui- 
tary disease  of  the  common  sarcomatous  type. 

DISEASES  OF  THE  ADRENALS 

Over-function  of  the  adrenals,  or  hypertrophy  of  adrenal  tissue, 
as  in  hypernephroma,  is  called  hyperchromaffinopathy,  or  hypere- 
pinephrinemia.  The  condition  is  supposed  to  be  responsible  for 
arteriosclerosis,  and  to  be  associated  with  Graves'  disease,  diabetes 
mellitus,  and  other  disturbances  of  internal  secretions.  Certain 
peculiar  types  of  pseudohermaphroditism  are  referred  to  this  dis- 
turbance, as  are  also  cases  of  premature  puberty,  and  other  dis- 
turbances in  the  development  of  the  sexual  characteristics. 

Diminished  function  leads  to  the  symptoms  of  Addison's  dis- 
ease. 

Addison's  disease  is  the  term  applied  to  the  symptoms  pro- 
duced by  disease  of  the  suprarenals.  It  is  characterized  by  slowly 
developing  weakness  of  the  skeletal,  visceral  and  vascular  muscles, 
emaciation,  and  a  peculiar  bronze-like  pigmentation  of  the  skin. 

Etiology.  Men  are  more  affected  than  women.  The  third  and 
fourth  decades  include  the  time  of  onset  in  most  cases.  Tubercular 
infection  is  responsible  for  the  disease  in  about  nine  tenths  of  the 
cases.  Other  causes  include  sarcoma  and  other  tumors,  and  the 
involvement  of  the  adrenals  in  disease  of  other  abdominal  organs. 


THB  ADRENALS  307 

Simple  atrophy  or  atrophy  depending  upon  a  chronic  interstitial 
inflammation  may  be  present,  for  which  sometimes  no  adequate 
cause  is  to  be  found. 

The  pathogenesis  of  the  condition  is  not  well  understood.  Sev- 
eral theories  have  been  offered  in  explanation  of  the  manner  in 
which  the  symptoms  of  Addison's  can  be  referred  to  disease  of  the 
suprarenal  capsules,  but  the  physiological  relationships  of  these 
organs  are,  as  yet,  too  little  known  to  warrant  any  adequate  state- 
ment concerning  their  relationships  in  disease. 

In  the  few  cases  reported,  lesions  of  the  eleventh  and  twelfth 
thoracic  vertebrae,  with  marked  muscular  tension  and  hypersen- 
sitiveness  in  the  immediate  neighborhood,  have  been  constant. 
These  lesions  may  be  either  produced  by  the  reflexes  (which  can 
be  produced  experimentally  in  animals)  or  they  may  be  causative 
factors. 

Diagnosis.  The  symptoms  are,  in  the  beginning,  atypical.  A 
noticeable  weakness  usually  appears  first;  this  is  associated  with 
extremely  weak  heart  beat  and  low  blood  pressure.  The  symptoms 
of  tuberculosis  are  usually  associated  with  these.  Gastro-intestinal 
symptoms  include  nausea,  vomiting  and  diarrhea.  The  appear- 
ance of  the  peculiar  discoloration  is  usually  necessary  to  a  diag- 
nosis. This  is  a  characteris\ic  bronze  color  and  it  may  be  at  first 
diffusely  spread  over  the  body,  or  it  may  appear  in  rather  well 
marked  patches.  It  is  worse  in  those  parts  of  the  body  which 
are  normally  darker,  as  around  the  nipples,  and  in  those  parts  sub- 
ject to  irritation  of  clothing,  as  around  the  waist.  It  is  distin- 
guished from  other  conditions  associated  with  pigmentation  by  its 
metallic  hue  and  by  the  presence  of  weakness,  low  blood  pressure, 
and  weak  heart. 

Since  the  symptoms  do  not  usually  appear  until  the  suprarenals 
have  been  almost  completely  destroyed,  it  is  evident  that  the  out- 
come is  necessarily  fatal.  Attempts  to  treat  the  condition  by  the 
use  of  adrenalin,  or  varying  combinations  of  extracts  of  the  supra- 
renal capsules,  with  the  extracts  from  other  ductless  glands,  have 
not  met  with  marked  success.  The  symptoms  must  be  met  with 
suitable  palliative  treatment,  but  in  typical  cases  with  no  hope  of 
avoiding  the  ultimate  fatal  outcome. 

Death  usually  occurs  from  exhaustion.  Sometimes  syncope, 
sometimes  delirium  precedes  death. 

Treatment.  The  treatment  is  largely  symptomatic  and  pallia- 
tive. The  muscular  contractions  should  be  kept  relieved ;  such 
other  lesions  as  may  be  found  should  be  corrected,  if  this  can 
be  done  without  too  great  discomfort.  The  diet  should  be  largely 
but  not  exclusively  cellulose — especially  the  raw  green  vegetables 
and  raw  fruits,  except  such  as  increase  the  diarrhea.  The  anemia 
associated  with  the  disease  is  met  by  the  treatment  for  secondary 


308  THE  DUCTLESS  GLANDS 

.  anemia,  (q  v.)  The  low  blood  pressure  and  muscular  weakness  cause 
less  discomfort,  and  the  progress  of  the  disease  is  delayed,  by  limit- 
ing the  amount  of  muscular  and  cardiac  exertion.  The  patient 
must  spend  much  time  resting  in  the  fresh  air,  mostly  in  the  recum- 
bent position.  He  may  take  walks,  slowly,  may  ride,  but  never 
hurry,  or  engage  in  any  exercise  which  requires  strenuous  effort. 

THE  PINEAL  BODY 

This  body  has  only  recently  been  studied  as  an  endocrine  gland. 
Cysts  or  tumor  of  the  pineal  body  may  compress  the  aqueduct  and 
thus  cause  internal  hydrocephalus,  or  may  exert  pressure  upon  the 
hypophysis  or  upon  the  cranial  nerves  or  their  nuclei.  Tliese  facts 
render  exact  diagnosis  of  pineal  disease  very  difficult. 

Premature  puberty  and  disturbances  of  carbohydrate  metabo- 
lism occur  in  pineal  disease.  Girls  may  menstruate  in  infancy.  In 
either  sex  the  genital  organs  may  reach  adult  size  very  early  in 
childhood.  Obesity,  cachexia  and  emaciation  may  be  associated 
with  the  disturbed  carbohydrate  balance. 

THE  GONADS 

The  interstitial  cells  of  Leydig  appear  to  be  responsible  for  the  internal 
secretion  of  the  testicle,  while  in  the  ovary  the  interstitial  cells  produce  an 
internal  secretion.  The  place  of  the  corpus  luteum  has  not  yet  been  determined. 
The  corpus  luteum  of  pregnancy  gives  evidence  of  endocrine  function,  while 
the  corpus  of  menstruation  yet  remains  almost  unstudied. 

Over-function  of  the  glands  is  associated  with  premature  sexual  develop- 
ment. Children  of  one  or  two  years  of  life  begin  to  show  abnormally  rapid 
skeletal  growth,  and  may  become  sexually  mature  within  a  few  months. 
Under-function  of  the  gonads  is  associated  with  deficient  development  of  the 
body.  Menstruation  is  lacking  or  scanty;  the  primary  and  secondary  sexual 
organs  remain  infantile,  the  voice  of  the  boy  remains  high.  Obesity  is  common 
in  both  boys  and  girls. 

Tuberculosis  or  pneumonia  terminate  the  life  in  most  cases,  usually  in  the 
early  twenties. 

MULTIGLANDULAR  DISEASES 

Several  glands  may  be  diseased  in  one  individual,  or  the  disease  of  one 
gland  may  affect  others,  thus  producing  complex  symptoms.  Sometimes  scle- 
rosis of  several  glands  is  found  at  autopsy.  The  effects  thus  produced  include 
variations  in  the  functions  of  many  organs. 

The  bones,  skin  and  hair  may  undergo  marked  changes.  Pigmentation  is 
frequently  noted.  Sexual  functions  are  modified.  Mentality  may  or  may  not 
be  affected,  but  emotionalism  is  often  marked.  Blood  pressure  varies,  and  is 
more  often  lowered.  Heart  action  is  variously  disturbed.  \A.lternate  constipa- 
tion and  diarrhea  may  occur.    Polydipsia  and  polyphagia  are  variably  present. 


CHAPTER  XXX 
.  UNCLASSIFIED  DISEASES 

PURPURA 

(The  purples) 

This  is  a  general  term  applied  to  subcutaneous,  submucous  or 
subserous  extravasations  of  blood.  In  its  most  easily  recog- 
nized form  spots  resembling  bruises  appear  upon  the  skin,  usually 
the  limbs,  without  being  caused  by  trauma.  Petechial  hem- 
orrhages, resembling  flea  bites,  also  occur,  and  may  be  overlooked 
in  making  the  diagnosis. 

Etiology.  Purpura  may  be  due  to  many  causes,  as  a  complica- 
tion or  symptom,  or  may  appear  without  recognizable  cause  (idio- 
pathic purpura).  It  is  often  present  in  severe  cases  of  the  infec- 
tious diseases  such  as  "black"  measles,  small-pox,  or  malaria, 
and  in  scurvy,  the  anemias  and  leukemias.  Certain  poisons, 
as  ergot,  the  iodids,  quinine,  antipyrin,  turpentine,  snake  venom, 
and  many  others  may  cause  purpura;  it  appears  in  some  nervous 
diseases,  hysteria,  myelitis,  and  others;  and  is  present  as  the  result 
of  mechanical  forces,  severe  coughing  and  vomiting,  arteriosclero- 
sis, heart  lesions ;  in  senility  several  agents  may  be  responsible 
for  the  condition. 

Idiopathic  Purpura  includes  several  types,  which  have  received 
difTerent  names. 

Purpura  Simplex  usually  occurs  in  children  before  puberty. 
Petechise,  vibices  or  ecchymoses  appear,  usually  upon  the  legs, 
■  especially  after  standing  or  running  more  than  usual.  The  spots 
are  slightly  sore,  and  present  the  changes  in  color  characteristic 
of  ordinary  bruises.  When  they  are  conspicuously  due  to  stand- 
ing, and  are  severe,  the  condition  is  orthostatic  purpura.  Rarely 
the  extravasation  of  blood  may  lead  to  the  blebs ;  joint  pains,  prob- 
ably hemorrhagic,  are  not  uncommon.  Diarrhea  is  frequent,  and 
blood  may  appear  in  the  stools ;  these  symptoms  may  be  present 
without  apparently  causing  any  particular  ill-health.  A  similar 
condition  occasionally  appears  at  about  the  climacteric,  in  either 
sex. 

Chronic  Purpura  is  probably  due  to  weakness  of  the  vessel 
walls,  and  may  be  present  for  years,  or  throughout  life,  without 
causing  any  serious  symptoms ;  the  ecchymoses  rarely  appear  upon 
parts  of  the  body  exposed  to  the  light,  and  evidences  of  internal 
hemorrhage  are  rare. 

309 


310  UNCLASSIFIED  DISBASBS 

•Factitious  Purpura  is  probably  associated  with  hysteria;  it  is 
characterized  by  irritability  of  the  vasomotor  centers,  plus  vascular 
Vi^eakness.  Any  sharp  irritation  of  the  skin,  as  by  a  pencil  mark, 
is  followed  by  purpuric  reaction;  it  is  possible  to  write  upon  the 
skin,  and  leave  the  letters  written  in  ecchymotic  colors.  It  is 
probably  related  to  dermographia.     (q.  v.) 

Henoch's  Purpura  occurs  in  children.  Swollen  joints,  extrav- 
asations of  blood  over  the  joints,  and  also  as  a  generalized  erup- 
tion ;  vomiting  and  diarrhea ;  epistaxis ;  and  the  presence  of  blood 
in  diarrheic  and  vomited  discharges,  and  in  the  urine,  are  the 
usual  symptoms.  Fever  is  slight,  nephritis  is  often  a  sequela.  The 
joints  are  painful,  and  abdominal  pain  is  often  very  severe. 

Peliosis  Rheumatica  (Schonlein's  Disease)  begins  with  sore 
throat  and  fever,  resembling  acute  rheumatism.  The  joints  are 
very  sore  and  are  swollen,  subcutaneous  edema  and  an  eruption 
which  may  be  urticarial,  petechial  or  ecchymotic  appears;  bullae 
may  be  filled  with  blood  (pemphigoid  purpura).  Bleeding  from 
the  mucous  surfaces — epistaxis,  hematemesis,  hematuria,  met- 
rorrhagia— may  occur.  There  may  be  extravasations  of  blood  into 
the  joint  cavities. 

Purpura  Hemorrhagica  (Werlhofif's  disease)  is  the  most  severe 
form  of  the  primary  purpuras.  It  is  probably  due  to  some  intense 
toxin  which  injures  the  endothelial  cells  of  the  blood  vessels.  It  is 
rather  more  frequently  found  among  young  women  than  else- 
where. After  a  day  or  a  few  days  of  malaise,  the  disease  appears 
rather  abruptly,  with  fever,  headache,  and  slight  bleeding  from 
some  mucous  membrane.  The  temperature  may  rise  to  105°  F.  or 
more;  the  bleedings  increase  in  amount  and  frequency;  death 
occurs  either  from  acute  anemia,  from  hemorrhage,  or  from  apo- 
plexy. In  Purpura  Hemorrhagica  Fulminans  death  results  within 
a  day  or  two — sometimes  before  the  bleeding  has  been  noticed 
upon  the  surface  of  the  body  at  all;  death  is  due  to  apoplexy  or 
to  hemorrhage  in  some  other  vital  organ.  The  diagnosis  must 
be  made  upon  the  symptoms,  in  those  cases  not  rapidly  fatal,  and 
is  possible  only  post-mortem  in  the  fulminating  form  of  the  disease. 

Diagnosis.  The  diagnosis  of  purpura  is  usually  difficult — the 
recognition  of  the  submucous,  subcutaneous,  and  internal  hem- 
orrhages is  not  often  difficult,  but  the  distinction  between  the  pri- 
mary and  secondary  forms,  and  the  finding  of  the  causative  fac- 
tors is  frequently  almost  impossible.  The  blood  examination  is 
necessary  in  all  cases ;  urine  analysis  is  indicated ;  while  the  history 
of  the  case  may  include  many  variable  factors  of  value. 

Treatment.  The  treatment  of  the  underlying  nutritional  disease 
is  of  first  importance.     Feeding  of  gelatine  is  often  advised;  in 


HEMOPHILIA  311 

some  cases  its  use  is  associated  with  good  results.    An  abundance 
of  fresh  air  is  always  indicated. 

Raising  the  ribs,  and  the  correction  especially  of  lesions  of  the 
thoracic  spine  are  always  indicated;  care  must  be  taken  to  avoid 
strenuous  movements ;  the  slightest  pressure  is  sometimes  followed 
by  the  appearance  of  large  ecchymoses  which  may  be  very  painful. 
The  diet  should  be  mixed,  including  considerable  proteid  and 
green  vegetables.  In  cases  associated  with  symptoms  of  toxemia, 
the  diet  should  not  include  the  purin  bases  very  abundantly.  Foods 
rich  in  calcium  are  indicated,  if  delayed  coagulation  is  a  factor  in 
the  hemorrhagic  tendency;  usually,  however,  it  is  the  weakness 
of  the  vascular  walls  that  permits  the  hemorrhagic  tendency. 

Prognosis.  In  purpura  simplex  the  prognosis  is  good  for 
speedy  and  complete  recovery,  especially  in  children.  In  the  rheu- 
matic type,  the  outlook  for  recovery  is  good,  but  may  be  slow. 
In  hemorrhagica  fulminans,  death  is  probably  inevitable  when  the 
diagnosis  is  made;  in  the  ordinary  hemorrhagic  type  death  may 
occur  at  any  time,  from  cerebral  or  other  hemorrhage,  but  recov- 
ery may  be  complete. 

HEMOPHILIA 

(Bleeder's  disease) 

Hemophilia  is  a  disease,  usually  hereditary,  in  which  hem- 
orrhages occur  profusely  upon  slight  provocation.  Nasse's  law, 
that  the  disease  exists  only  in  males,  but  is  transmitted  only  by 
females,  has  many  exceptions.  Females  do  sometimes  have  the 
disease,  and  it  is  sometimes  transmitted  by  males  without  the  inter- 
vention of  female  blood — directly  from  father  to  son,  for  example. 
The  law  holds  for  most  cases,  however,  and  females  in  the  fam- 
ilies of  bleeders,  and  bleeders  themselves,  should  avoid  marriage. 
Men  in  bleeder  families  are  able  to  marry  safely,  however. 
Strangely  enough,  while  women  may  be  bleeders,  they  rarely  die 
in  the  menstrual  period  or  in  childbirth,  though  they  may  die  of 
hemorrhage  from  a  scratch  or  the  pulling  of  a  tooth.  The  most 
important  factor  seems  to  be  a  weakness  of  the  walls  of  the  capil- 
laries and  other  blood  vessels,  though  a  deficient  coagulability  of 
the  blood  is  present  in  some  cases.  Spontaneous  hemorrhages 
upon  the  mucous  membranes,  or  into  the  joint  cavities  may  occur. 

Diagnosis.  The  patient  is  usually  aware  of  his  peculiarity  early 
in  life,  from  his  bloody  experiences  with  slight  wounds  of  boyhood. 
Rarely,  the  first  hemorrhage  is  fatal. 

Treatment  is  mostly  prophylactic.  No  surgical  operations 
should  be  performed  upon  a  "bleeder"  except  as  a  very  last  resort 
in  a  case  otherwise  hopeless.  Circumcision,  tonsillectomies,  are 
best  omitted.    Teeth  should  not  be  lanced,  nor  pulled  if  this  can  be 


312  UNCLASSIFIED  DISEASES 

avoided.    Strong  massage  around  a  wound  may  increase  the  forma- 
tion of  thrombin  by  the  tissue  cells. 

Feeding  of  gelatine  has  been  employed;  it  seems  to  increase 
the  viscidity  of  the  blood,  and  apparently  its  coagulability. 
Increased  amount  of  the  calcium-containing  foods  is  advised. 

Prognosis.  These  men  usually  die  of  hemorrhage,  sooner  or 
later.    The  disease  itself  does  not  interfere  with  life  or  health. 


DISEASES  OF  THE  SPLEEN 

'The  function  of  the  spleen  is  as  yet  unknown.  It  is  composed 
chiefly  of  tissue  which  greatly  resembles  ordinary  lymphoid  tissue 
and  it  is  certainly  associated  in  some  way  with  the  development 
of  the  white  blood  cells  and  with  the  disintegration  of  those  red 
blood  cells  whose  term  of  usefulness  is  past.  The  spleen  is 
enclosed  in  a  muscular  capsule  and  this  is  innervated  from  the 
eighth,  ninth  and  tenth  thoracic  spinal  segments.  The  spleen 
undergoes  marked  variations  in  its  size,  which  appear  to  be  due 
to  the  nervous  control  of  the  muscular  fibers  of  its  capsule  and 
to  the  variations  in  the  circulation  of  the  abdominal  viscera.  It 
seems  to  act  as  a  reservoir  for  the  blood  content  of  the  abdomen. 
Lesions  of  the  seventh  to  the  tenth  vertebrae  and  the  corre- 
sponding ribs  cause  a  relaxation  of  the  muscular  capsule  and  pre- 
dispose to  splenitis.  The  relationship  of  these  lesions  to  spleno- 
meduUary  leukemia  is  discussed  in  connection  with  that  disease. 

Splenic  hyperemia  passes  by  degrees  into  acute  splenitis.  The 
bony  lesions  above  mentioned  predispose  to  splenitis.  During  any 
of  the  infectious  fevers,  or  any  acute  inflammatory  process  of  the 
abdominal  viscera,  the  spleen  is  likely  to  become  involved. 

Diagnosis  is  rarely  possible,  the  treatment  is  that  of  the  primary 
disease  and  the  prognosis  for  recovery,  so  far  as  the  spleen  is  con- 
cerned, is  usually  good.  The  consideration  of  the  various  forms 
of  splenitis  are  chiefly  pathological  in  interest. 

Embolism  is  not  infrequent.  The  infarcts  are  small  and  usually 
terminate  as  small  white  fibrous  masses.  After  infection  occurs, 
localized  abscesses  are  produced.  Because  of  the  peculiar  structure 
of  the  spleen,  hemorrhages  of  small  degree  are  not  recognizable. 
Profound  hemorrhages  may  rupture  the  wall  of  the  spleen  and 
the  blood  thus  escape  into  the  peritoneal  cavity. 

Interstitial  Splenitis  leads  to  an  overgrowth  of  the  connective 
tissue  of  the  trabeculae  which  is  constant  and  does  not  terminate 
by  any  apparent  shrinkage.  The  cirrhotic  spleen  is  larger  than 
the  normal  spleen,  and  has  a  tendency  to  constantly  increase  in 
size.     ^ 


STATUS  LYMPHATICUS  313 

Proliferative  splenitis  follows  typhoid  and  other  acute  fevers, 
and  reaches  its  most  pronounced  extent  after  malaria.  The  "ague 
cake"  characteristic  of  chronic  malaria  is  of  this  type.  The  tre- 
mendously large  spleen  of  leukemia  is  associated  with  a  chronic 
proliferative  process  of  the  spleen  pulp. 

Splenitis  causes  a  heavy,  aching  pain  over  the  left  ribs  and  is 
associated  with  reflex  muscular  contractions,  involving  the  lower 
intercostals  and  interthoracic  region,  and  sometimes  the  small  of 
the  back.  Pain  over  the  tip  of  the  left  shoulder  is  frequently 
found  and  the  tissues  over  the  top  of  the  shoulder  and  around  the 
lower  part  of  the  neck  are  usually  hypersensitive.  The  ribs  on  the 
left  side  may  be  raised  and  separated  as  the  result  of  the  splenic 
enlargement,  or  they  may  be  drooping  and  approximated  as  the 
result  of  the  reflex  muscular  contractions. 

Amyloid  degeneration  of  the  spleen  (sago  spleen)  occurs  in 
connection  with  amyloid  diseases  affecting  the  other  viscera.  The 
malphigian  bodies  possibly  are  chiefly  and  sometimes  solely 
affected.  It  is  to  this  fact  that  the  name  sago  spleen  is  due.  The 
disease  may  extend  to  the  splenic  pulp  and  trabeculae,  until  prac- 
tically the  whole  organ  may  become  involved  in  the  degenerative 
process.  No  treatment  is  possible  and  death  cannot  be  very  long 
delayed  after  the  recognition  of  this  splenic  disease. 

Primary  Splenic  Tumors  are  rare,  except  for  the  peculiar  over- 
growth which  occurs  in  leukemia.  This  is  probably  to  be  consid- 
ered an  adeno-lymphoma  and  it  may  reach  tremendous  size. 
Leukemia,  on  the  other  hand,  is  sometimes  considered  a  form  of 
sarcomatous  growth. 

Secondary  Neoplasms  are  rather  common.  Carcinoma  of  the 
spleen  usually  originates  in  the  stomach  or  duodenum.  By  far  the 
most  common  cause  of  splenic  tumors  is  found  in  tubercular  or 
syphilitic  infection.  Splenic  tubercles  may  reach  considerable 
size  and  they  may  abound  throughout  the  splenic  pulp.  Syphilitic 
gummata  may  be  very  large  and  often  associated  with  amyloid 
degeneration. 

STATUS  LYMPHATICUS 

This  is  a  peculiar  disease  of  childhood  characterized  by  a  per- 
sistent thymus  and  marked  enlargement  of  the  thymus,  spleen  and 
all  other  lymphoid  tissues  of  the  body,  which  often  manifests  itself 
first  by  the  sudden  death  of  the  patient. 

The  etiology  of  the  disease  is  completely  unknown.  Its  exist- 
ence is  rarely  recognized  ante-morterh.  Children  so  affected  die 
suddenly  upon  very  slight  provocation.  Anesthesia  itself  or  a 
very  slight  surgical  operation  such  as  circumcision  or  the  removal 
of  adenoids  may  result  in  sudden  death.  More  rarely  a  child 
may  die  as  the  result  of  a  fall,  or  of  fright.    At  a  post-mortem  it  is 


314  UNCIASSIFIBD  DISBASES. 

found  that  the  thymus  extends  well  down  into  the  thorax  and 
around  the  heart.  In  a  few  cases,  careful  physical  examination 
ante-mortem  shows  the  increased  thymic  dullness,  enlarged  spleen 
and  enlarged  superficial  lymphatic  nodes.  Children  in  whom  these 
conditions  are  found  must  be  carefully  guarded  against  shocks  or 
fright  until  atrophy  of  the  thymus  occurs. 

Though  the  condition  is  rare,  the  seriousness  of  its  occurrence 
should  lead  to  the  careful  examination  of  children  before  surgery 
or  anesthesia  is  advised. 


MOUNTAIN  SICKNESS 

Mountain  sickness  is  a  condition  due  to  rarefied  air,  and  which 
develops  in  high  altitudes.  It  is  characterized  by  severe  headache, 
gasping  for  breath,  parched  tongue,  intense  thirst,  loss  of  appetite, 
and  an  intense  malaise.  There  may  be  a  slight  fever.  It  may  be 
a  transient  condition  or  may  last  for  several  days. 

In  a  less  degree,  it  occurs  in  moderate  altitudes  in  susceptible 
individuals.  Tubercular  individuals  who  go  to  high  altitudes  often 
suffer  very  severely  from  mountain  sickness.  In  some  cases  this 
clouds  the  diagnosis  of  tubercular  systemic  infection.  The  involve- 
ment of  the  meninges,  especially,  gives  sym.ptoms  not  easily  dis- 
tinguishable from  mountain  sickness',  and  this  may  lead  to  serious 
error  in  prognosis. 

The  treatment  must  be  based  upon  the  patient's  general  con- 
dition. He  should  be  put  to  bed  at  first,  and  kept  on  either  a  very 
dry  diet,  with  water  given  only  between  meals,  in  small  quantities 
sipped  slowly,  or  on  a  completely  liquid  diet,  taken  in  small  quan- 
tities, sipped  slowly.  As  the  symptoms  diminish  he  may  take 
more  food.    The  iron-containing  foods  are  needed. 

A  patient  whose  physique  is  poor,  especially  those  who  are 
tubercular,  should  be  sent  to.  lower  altitudes  if  the  symptoms  do 
not  clear  up  within  a  few  days — or  even  earlier,  if  the  symptoms 
are  severe. 

Susceptibility  to  mountain  sickness  may  be  based  upon  low 
hemoglobin,  weak  heart,  valvular  lesions,  "nervous"  heart;  bony 
lesions  affecting  the  cardiac,  gastric,  or  vasomotor  centers ;  chronic 
inflammations  affecting  the  middle  or  inner  ear.  Suitable  treat- 
ment for  these  conditions  may  enable  the  individual  previously 
susceptible  to  mountain  sickness  to  live  comfortably  in  high  places. 

SEASICKNESS 

This  is  a  disease  due  to  irregular  motion  of  the  body,  charac- 
terized by  nausea  and  usually  vomiting,  sometimes  intense  head- 
ache, and  always  very  severe  sensations  of  extreme  illness,  which 
are  indescribable. 


RAYNAUD'S  DISEASE  315 

Etiology.  Primarily,  the  illness  is  due  to  the  motion  of  the 
boat.  Predisposing  causes  include  disturbances  of  the  digestive 
tract  and  the  nerve  centers.  -Bony  lesions  of  the  upper  cervical 
region  are  important  factors.  Seasickness  is  "no  respecter  of  per- 
sons," and  people  in  excellent  health  may  succumb  while  those  of 
deficient  vitality  remain  comfortable;  the  opposite  relation  is  also 
true.  The  same  person  may  be  free  for  many  voyages,  only  to 
succumb  at  some  more  or  less  unpleasant  time.  Usually  one 
becomes  exempt  after  a  few  hours  or  days,  but  some  people  never 
become  adapted  to  the  motion  of  a  boat.  No  doubt  the  odors  and 
sights  are  also  factors,  though  these  are  popularly  exaggerated. 

Carsickness  is  the  same  disease,  appearing  among  those  riding 
upon  swaying  railroad  coaches. 

Pathogenesis.  The  disorder  is  probably  due  to  the  effects  of  the 
motion  upon  the  vestibular  nerves,  and  the  effects  of  this  irritation 
upon  the  visceromotor  centers  in  the  basal  centers  and  the  medulla. 

Treatment.  Rest  in  bed  with  plenty  of  fresh  air  is  the  best 
thing.  Plentiful  liquid  intake  is  good  in  some  cases,  very  dry 
diet,  eaten  slowly,  gives  good  results.  "General  treatment"  often 
terminates  an  attack. 

Prophylaxis.  Before  voyage,  the  digestive  tract  should  be 
known  to  be  clean.  The  cervical  region  should  be  examined  and 
lesions  corrected;  also  the  thoracic. 

Prognosis.  The  disease  terminates  with  the  voyage.  Elderly 
or  weakly  persons  may  die,  though  rarely. 


RAYNAUD'S  DISEASE 

(Symmetric  gangrene) 

This  is  a  disease  apparently  affecting  the  vasomotor  nerves, 
and  characterized  by  circulatory  disturbances  and  later  gangrene 
of  the  peripheral  parts  of  the  body,  especially  the  fingers  and  toes. 

Several  grades  of  the  affection  have  been  described.  In  none 
of  these  is  a  satisfactory  etiology  known.  Exposure  to  cold  is  the 
most  common.    The  condition  resembles  "frost-bite"  slightly. 

Diagnosis.  Very  early  in  the  course  of  the  disease,  variations 
in  the  size  of  the  pupils  and  especially  dilatation  affecting  both 
pupils  is  noticed.  Local  syncope  is  characterized  by  pallor  and 
numbness  of  the  fingers  of  both  hands.  There  may  be  neuralgic 
pains  and  peculiar  sensory  disturbances  in  the  arms.  These  attacks 
may  be  precipitated  by  cold  and  occur  more  frequently  during  the 
autumn  and  spring  seasons.  Such  attacks  may  be  caused  by  emo- 
tional disturbances.  Pseudo-Raynaud's  is  hysterical  local  syncope. 
It  is  not  followed  by  gangrene. 


316  •  UNCLASSIFIED  DISEASES 

Raynaud's  disease  is  certainly  due  in  some  cases  to  lesions  of 
the  third  and  fourth  thoracic  vertebrae  and  the  corresponding  ribs. 
Several  very  typical  cases  have  been  reported  in  which  recovery 
has  followed  correction  of  such  lesion.  In  one  case  at  least,  no 
recurrence  has  appeared  for  ten  years  after  such  correction. 
(P.  C.  O.) 

Local  asphyxia  is  a  more  severe  grade  of  the  vasomotor  dis- 
turbance. The  fingers  or  toes  are  blue  and  edematous ;  there  is 
much  aching,  especially  after  the  attack  passes  away.  This  condi- 
tion may  affect  the  tips  of  the  ears  and  the  nose,  as  well  as  some 
other  parts  of  the  body  more  rarely.  Hemoglobin  may  be  found 
in  the  urine.  Trophic  changes  characterized  by  ridges  upon  the 
finger  nails  and  by  skin  lesions  of  the  affected  part  may  be  noted. 
Following  this,  gangrene  may  appear.  The  fingers  soften,  blebs 
appear  under  the  skin  and  unless  recovery  occurs  speedily,  the 
fingers  fall  off.  Autolytic  enzymes  digest  the  dead  tissue  which 
may  dry  away,  leaving  the  fingers  mummified  (dry  gangrene). 

The  injured  part  may  drop  off,  leaving  a  stump.  This  may  heal 
over  and  the  progress  of  the  disease  be  stopped. 

The  treatment  consists  in  thorough  corrective  work  applied  to 
the  upper  thoracic  and  cervical  spine.  General  measures  for  in- 
creased nutrition  are  helpful.  In  the  first  and  second  stages,  the 
prognosis  is  very  good;  and  even  after  considerable  destruction  of 
tissue,  the  progress  of  the  disease  may  be  stopped  and  the  patient 
make  remarkably  good  recovery. 

ANGIONEUROTIC  EDEMA 

This  IS  a  disease  of  unknown  cause,  characterized  by  the  sudden 
appearance  of  localized  swellings  of  the  skin  or  mucous  membrane. 

Aside  from  a  slightly  neurotic  tendency  on  the  part  of  these 
individuals,  nothing  of  etiological  importance  can  be  found.  The 
disease  rarely  affects  females  and  is  most  likely  to  appear  during 
early  adult  life. 

The  edema  usually  appears  suddenly  and  disappears  with  equal 
rapidity.  Any  part  of  the  body  may  be  affected.  In  a  few 
instances,  edema  of  the  glottis  has  caused  death.  Aside  from  the 
annoyance  due  to  the  presence  of  the  swellings  upon  the  face, 
hands,  or  other  parts  of  the  body,  no  evil  results  are  usually 
present. 

The  treatment  should  be  directed  to  the  underlying  neurotic 
condition.    The  prognosis  is  uniformly  good. 

SUNSTROKE 

(Insolation;  thermic  fever;  heat-stroke;  coup  de  soleil;  siriasis) 

*   Sunstroke  is  an  attack  due  to  excessive  heat,  and  characterized 

by  marked  increase  in  the  body  temperature,  rapi4  heart,  syncope,^ 


SUNSTROKE    .  317 

coma,   delirium,  or  other  nervous  symptoms,  and  sometimes  by- 
symptoms  referable  to  hemorrhages  in  various  parts  of  the  body. 

Etiology.  Among  the  contributing  causes  may  be  mentioned 
excessive  bodily  fatigue,  depression  due  to  long  exposure  to  the 
heat ;  insufficient  food  and  the  overuse  of  alcoholic  drinks.  In  true 
sunstroke  the  brain  shows  parenchymatous  degeneration.  After 
death,  the  whole  body  is  found  in  a  state  of  venous  congestion,  the 
left  ventricle  firmly  contracted  and  the  right  heart  and  vessels 
engorged  with  dark  fluid  blood.    Rigor  mortis  is  early  and  marked. 

Sunstroke  is  properly  applied  to  those  working  under  the  direct 
rays  of  the  sun ;  the  violet  rays,  as  well  as  the  red  rays,  are  active. 
Men  who  work  hard,  and  are  heavily  clothed,  are  especially  liable 
to  sunstroke.  Farmers  and  soldiers  on  the  march  suffer  in  this 
way. 

Heat  Stroke  or  Thermic  Fever  occurs  in  men  who  work  hard 
in  intense  heat,  but  in  dim  light.  Bakers,  engineers,  fireman, 
are  very  liable  to  heat  stroke.  In  all  these  cases  the  temperature 
of  the  body  is  high. 

Heat  Apoplexy  may  occur  under  any  of  the  preceding  condi- 
tions. There  are  some  prodromal  symptoms  referable  to  the  heat, 
dizziness,  visual  disturbances,  and  dyspnea.  Sweating  may  cease; 
the  patient  may  fall  in  coma  or  convulsions,  and  die  immediately; 
or  he  may  remain  convulsive  or  delirious  and  recover  in  a  few 
days,  or  finally  die  as  the  result  of  the  injury.  The  temperature 
rises  very  high,  reaching  115°,  or  more,  in  fatal  cases.  Such  tem- 
perature, maintained  for  more  than  a  very  few  minutes,  must 
coagulate  the  globulins  of  the  entire  body  and  render  death  inev- 
itable. 

Heat  Prostration  has  milder  symptoms,  unconsciousness  does 
not  occur,  and  recovery  is  to  be  expected. 

Heat  Cramps,  myospasm,  due  to  direct  injury  to  the  muscle 
cells,  occur  in  men  whose  work  is  hot  and  exhausting — stokers  on 
steam  ships,  for  example.  The  calves  are  most  affected;  they 
contract  rigidly  with  much  pain.  The  paroxysms  last  less  than 
a  minute,  and  recur  almost  at  once ;  the  attacks  may  last  a  day 
or  longer;  recovery  is  attended  with  soreness  and  exhaustion. 

In  any  form  of  heat  injury,  the  blood  is  dark,  thin,  either  feebly 
alkaline  or  slightly  acid  and  the  coagulation  time  is  exceedingly 
slow  or  absent.     The  blood  pressure  is  low. 

It  is  important  to  distinguish  between  sunstroke  and  heat 
exhaustion,  and  also  between  these  and  alcoholic  coma,  apoplexy 
and  epilepsy. 

The  sequelae  include  headache,  vertigo,  insomnia,  inability  to 
bear  high  temperature,  loss  of  power  of  concentration,  failure  of 


318  UNCLASSIFIED  DISEASES 

memory,  peripheral  neuritis,  epilepsy,  mental  enfeeblement,  mono- 
plegia, paraplegia,  or  hemiplegia. 

Treatment.  Remove  the  patient  to  a  cool  place,  place  in  the 
recumbent  posture  with  the  head  low,  loosen  clothing,  stimulate 
the  respiratory  and  cardiac  spinal  areas  from  second  to  fifth  dorsal 
and  directly  over  the  heart.  In  hyperpyrexia  cold  douching  to  the 
head  is  the  first  indication,  with  strong  relaxation  of  the  cervical 
muscles.  Remove  to  a  hospital  as  soon  as  possibly  where  cold 
baths,  cold  pack,  or  rubbing  with  ice  can  be  used  until  the  tem- 
perature is  reduced.  Cold  enteroclysis  or  hypodermoclysis  may 
be  used.  Keep  the  whole  spinal  musculature  relaxed  as  the  mus- 
cles are  usually  very  contracted,  paying  particular  attention  to 
the  cervical  region.  Tonic  treatment  is  necessary  during  the 
stage  of  depression  and  during  convalescence. 

Prognosis.  Hyperpyrexia  has  unfavorable  outlook,  death  re- 
sulting in  one  h&lf  to  several  hours  in  many  cases.  Permanent 
injury  results  if  death  is  avoided. 

The  unfavorable  indications  are :  increased  temperature,  cardiac 
failure,  convulsions,  absent  reflexes,  followed  by  complete  mus- 
cular relaxation. 

The  favorable  indications  are:  decline  in  surface  heat  and  in 
axillary  and  rectal  temperature,  stronger  pulse,  increased  depth 
of  respiration,  restored  reflexes,  and  return  of  consciousness. 

HEAT  EXHAUSTION 

This  is  a  state  of  asthenia  or  collapse  due  to  overwork  in  hot, 
usually  dark  and  unaired  places,  such  as  furnace  rooms,  foundries, 
etc.  It  may  also  occur  in  weak  children  or  older  persons,  in  hot, 
unaired  rooms,  especially  in  tenement  districts.  The  exhaustion 
of  the  vasomotor,  heart  and  other  nerve  centers  is  due  to  the 
increased  viscosity  and  toxicity  of  the  blood,  resulting  from  in- 
creased perspiration  and  diminished  urine  and  other  secretions. 
Fatigue,  any  form  of  toxemia,  alcoholism  or  other  drug-taking, 
weakening  diseases,  mal-nutrition,  all  predispose. 

Diagnosis.  The  most  important  symptom  is  the  hypothermia, 
sometimes  to  95°  F.  or  even  lower.  Marked  pallor,  weakness, 
vertigo,  syncope  or  delirium,  weak  pulse  and  low  blood  pressure 
are  characteristic.  The  skin  is  clammy;  symptoms  of  apoplexy 
may  occur.  Death  may  be  sudden  or  delayed  for  hours,  or  recov- 
ery may  occur. 

.  Treatment  should  be  stimulating.  The  patient  should  be 
placed  in  bed,  if  possible ;  plenty  of  fresh  air  is  essential.  Warmth 
is  necessary ;  heat  may  be  applied  to  feet  and  body.  Liquids  must 
be  speedily  added ;  hot  drinks,  tea,  coffee,  hot  lemonade,  warm 


'SNOW  DELIRIUM  319 

enemas,  sometimes  hypodermoclysis  or  enteroclysis  are  to  be 
employed  for  this  purpose.  Friction  of  the  limbs  should  be  vig- 
orous. 

The  heart  centers  are  stimulated  by  work  in  the  upper  thoracic 
and  cervical  region,  and  over  the  apex  region;  the  ribs  are  to  be 
raised  and  the  flexibility  of  the  thorax  increased;  pressure  over 
the  liver,  suddenly  released,  is  useful, 

A  warm  bath  and  warm  enema  may  be  given,  if  convenient. 
The  patient  should  be  put  to  bed,  if  possible,  or  placed  in  a 
reclining  position,  with  fresh  air,  warm  covering,  and  heat  at 
feet  and  perhaps  near  the  body.  Friction  over  the  limbs  is  useful. 
In  applying  friction  and  heat,  the  danger  of  injuring  the  skin  of 
an  unconscious  person  must  not  be  forgotten.  Drugs  and  alcohol 
are  dangerous.  Hot  drinks,  such  as  broth,  tea,  or  coffee  may  be 
freely  given;  it  is  necessary  to  add  liquids  to  body  rapidly. 

With  returning  consciousness  and  increasing  heat,  chilling  and 
overwarmth  must  be  equally  avoided. 

Sequelae.  The  symptoms  of  the  attack  persist  for  some  time, 
in  severe  cases.  The  patient  must  avoid  overwork  and  overheat 
for  some  months,  and  may  be  unable  to  endure  extremes  of  heat 
for  several  years.  Frequent  bathing,  wholesome  food,  the  avoid- 
ance of  alcoholic  drinks  and  of  excessive  heat,  should  diminish 
the  tendency  to  recurrence. 


SNOW  BLINDNESS  AND  DELIRIUM 

People  who  are  exposed  to  the  glare  of  snow  and  ice,  especially 
in  great  cold,  suffer  from  a  peculiar  ocular  disturbance,  due  to  the 
effects  of  the  constant  strain  upon  the  eye  muscles  which  are  often 
totally  unable  to  protect  the  retina  from  the  evil  effects  of  exces- 
sive light.  The  ultra-violet  rays  are  especially  disastrous  in  the 
glare  from  the  snow.  The  glare  from  the  desert  and  the  glare 
from  the  electric  lights  give  similar  but  usually  less  disastrous 
reactions.  Blindness  may  occasionally  persist,  but  it  usually  dis- 
appears with  rest  from  the  intense  light.  It  may  be  necessary  to 
wear  dark  bandages  for  days,  and  to  remain  in  a  dark  room,  and 
then  to  wear  dark  glasses  for  weeks  or  months,  after  a  severe 
exposure. 

The  effects  produced  upon  the  entire  system,  and  upon  the 
mind,  by  the  glare  and  the  snow,  may  be  serious.  The  isolation 
of  individuals  in  the  extremes  of  Arctic  and  Antarctic  latitudes, 
the  difficulty  of  securing  proper  foods,  the  desolation  of  the  sur- 
roundings, all  tend  to  develop  a  mental  and  physical  depression. 
The  mental  effects  include  increasing  irritability,  and  a  sense  of 
the  unreal ;  hallucinations  are  frequent,  and  quarrels  among  friends 
are  not  rare.     Gastro-intestinal  disturbances  are  sometimes   due 


320  UNCLASSIFIED  DISEASES 

to  poor  food,  but  appear  to  be  inevitable  even  with  good  food. 
Constant  nausea,  vomiting  and  diarrhea  are  usually  associated  with 
scurvy;  attacks  of  these  symptoms  occur  without  recognizable 
causes.  The  cold  air  leads  to  various  pulmonary  diseases,  espe- 
cially tuberculosis  and  pneumonia. 

All  symptoms  disappear  rapidly  with  return  to  the  latitudes  to 
which  the  patients  have  been  accustomed.  Colored  glasses  pre- 
vent the  trouble  to  some  extent. 

DESERT  SICKNESS 

The  intensely  dry  air  of  the  desert,  plus  the  desolation  and 
isolation,  the  glare  of  the  sunshine,  and  the  intense  heat,  often 
affect  those  who  first  visit  the  desert.  The  effects  are  more  pro- 
nounced in  the  higher  altitudes. 

Nausea,  vomiting  and  other  symptoms  of  mountain  sickness, 
are  frequent.  The  dryness  causes  roaring  of  the  ears,  which  may 
be  severe.  Increased  thirst  leads  to  the  drinking  of  too  much  ice 
water,  if  it  is  available,  and  gastritis  may  result;  the  condition  is 
more  severe  if  alcoholic  drinks  are  used. 

The  quivering  light  rays  lead  to  hallucinations ;  this  is  magni- 
fied by  the  occurrence  of  the  mirage,  with  its  strange  and  varying 
pictures. 

If  water  is  lacking,  the  symptoms  are  serious.  In  the  dry  air, 
the  mucous  membranes  dry  out  rapidly,  and  the  effects  are  apparent 
in  every  organ  of  the  body.  Delirium  results  rapidly.  The  mirage 
is  not  recognized,  and  a  wild  dash  for  the  water  and  greenery  thus 
seen  often  leads  to  hasty  death.  A  peculiar  effect  is  the  tendency 
to  remove  the  clothing;  shoes  are  thrown  away,  the  hat,  and  ulti- 
mately every  thread  of  clothing  is  removed.  Death  occurs  from 
exhaustion. 

SIMPLE  CONTINUED  FEVER 

(Febricula;  irritation  fever;  ephemeral  fever) 
Simple  continued  fever  is  an  acute,  noncontagious  disease  of 
short  duration  and  of  mild  type  unattended  by  characteristic 
lesions,  occurring  most  commonly  in  childhood  and  arising  from 
gastro-intestinal  disturbances,  mental  or  physical  fatigue,  excite- 
ment, emotion,  or  exposure  to  high  degrees  of  heat  or  cold. 

Diagnosis.  The  onset  is  sudden,  may  be  ushered  in  with  nausea 
and  vomiting,  convulsions  or  chill.  There  is  great  lassitude,  tem- 
perature rises  suddenly  to  102°  to  103°  F..  accompanied  by  head- 
ache, increased  respiration,  quick,  tense  pulse,  dryness  of  the  skin, 
thirst,  coated  tongue,  constipation  and  febrile  urine.  Delirium  may 
be  present.  There  is  no  characteristic  eruption ;  herpes  is  common 
on  the  lips. 


SIMP  LB  FEVER  321 

The  duration  is  short,  if  lasting  for  a  day  and  completely 
disappearing  is  called  ephemeral  fever;  if  persisting  for  three  or 
more  days  without  any  local  affection,  it  is  then  called  febricula, 
or  continued  fever.  The  affection  terminates  by  lysis  or  crisis, 
and  convalescence  is  rapid. 

Treatment.  Rest  in  bed  is  the  first  consideration.  Then  a  gen- 
tle, thorough  spinal  treatment  from  occiput  to  coccyx,  paying 
particular  attention  to  the  thoracic  area  and  adjusting  every  devia- 
tion found,  and  lastly  giving  direct  manipulation  to  the  abdomen 
to  secure  free  elimination.  An  enema  may  be  given  at  first.  The 
diet  should  be  liquid,  preferably  fruit  juices  and  plenty  of  water. 

Prognosis.  Recovery  occurs  without  after-effects.  Future 
attacks  are  prevented  by  the  correction  of  hygiene,  diet,  and  regu- 
lation of  hours  of  play. 

ANAPHYLAXIS 

This  condition  has  not  been  sufficiently  studied  to  warrant  its 
classification.  It  appears  to  be  a  factor  in  the  pathogenesis  and 
symptomatology  of  certain  infections,  certain  cases  of  hay  fever 
and  asthma,  proteid  poisonings,  autointoxication,  urticaria,  and  in 
some  cases  of  personal  idiosyncrasy.  Its  importance  increases  with 
the  tendency  to  employ  serums  in  the  treatment  of  disease. 

Foreign  proteids  in  the  blood  stream  produce  sensitization 
within  a  few  days  to  a  few  weeks.  The  amount  injected  is  not 
important ;  either  extremely  minute  or  very  large  doses  appear  to 
produce  equal  effects.  After  this  sensitization,  further  injections 
of  this  proteid  may  produce  immediate  and  very  serious  symptoms, 
including  respiratory  and  circulatory  disturbances,  urticaria,  syn- 
cope, paralysis,  and  other  nervous  symptoms,  diarrhea  and  vomit- 
ing, and  often  death  within  a  few  minutes  or  several  hours. 

Sensitization  persists  throughout  life,  and  may  be  transmitted 
from  mother  to  offspring.  Both  the  sensitizing  and  the  activating 
doses  may  gain  entrance  into  the  body  in  one  or  more  of  several 
different  ways.  Recently  the  use  of  serums  in  diagnosis,  prophy- 
laxis, and  therapeutics  is  responsible  for  injection  of  foreign 
serums,  usually  horse  serum,  directly  into  the  circulation.  Inhala- 
tion may  be  efficient  as  in  cases  of  asthma  from  association  with 
horses.  Absorption  may  occur  through  abrasions  but  not,  appar- 
ently, through  healthy  skin.  Absorption  may  occur  through  the 
walls  of  the  alimentary  tract,  as  in  urticaria  from  eating  straw- 
berries, shell-fish,  or  other  articles  of  food  by  persons  sensitive  to 
them.  In  this  case  it  may  be  that  the  products  of  imperfect 
digestion  of  the  foods  are  the  efficient  agents,  rather  than  the  pro- 
teids of  the  foods  themselves. 


CHAPTER  XXXI 
CHRONIC  DRUG  POISONING 

GENERAL  DISCUSSION 

For  the  recognition  and  treatment  of  accidental  and  suicidal 
poisoning,  books  on  toxicology  must  be  consulted.  But  chronic 
poisoning  often  confuses  the  diagnosis  of  organic  disease,  and  is 
so  often  associated  with  organic  disease,  that  a  short  description  of 
the  more  common  of  these  is  included  in  this  volume. 

Generally  speaking,  the  treatment  of  the  chronic -poisonings 
depends  upon  stopping  the  intake  and  hastening  the  elimination 
of  the  drugs.  It  is  rarely  harmful  to  stop  the  drug  suddenl}'^ ;  in 
a  very  few  cases  its  gradual  diminution  may  be  necessary  on 
account  of  the  weakness  of  the  patient.  Elimination  may  be  has- 
tened only  by  the  use  of  the  milder  measures — the  use  of  emetics 
and  purgatives  is  limited  to  the  acute  poisonings.  Antidotes  are 
rarely  of  value  in  the  chronic  cases,  since  in  these  the  drug  is  within 
the  fluids  of  the  body,  and  probably  in  some  cases  within  the  cells 
themselves.  The  treatment  finally  narrows  down  to  the  efforts 
made  to  keep  the  eliminating  organs  in  the  best  possible  condi- 
tion, and  to  keep  the  blood  flowing  as  rapidly,  with  normal  pressure, 
as  possible.  It  is  necessary  in  some  cases  to  provide  new  blood 
cells  as  rapidly  as  possible.  This  is  secured  by  good  food,  good 
circulation  through  the  red  bone  marrow,  and  the  usual  treatment 
for  secondary  anemia. 

It  is  suggested  that  the  organs  of  elimination  might  be  induced 
to  work  beyond  their  normal  capacity.  This  is  possible,  for  a 
short  time,  but  a  reaction  is  bound  to  occur,  so  that  the  ultimate 
efficiency  of  any  organ  is  lessened.  In  acute  poisoning,  the  rapidity 
of  elimination  may  be  so  necessary  that  the  later  inactivity  of  the 
eliminating  organs  becomes  a  negligible  matter ;  in  chronic  poison- 
ing, the  need  for  good  elimination  persists  for  days,  sometimes  for 
weeks,  and  any  attempts  to  stimulate  liver,  kidneys  or  bowels 
to  greater  activity,  by  adding  yet  other  poisonous  substances  to 
the  blood  circulating  through  them,  must  ultimately  interfere 
with  the  elimination  of  the  poison  for  which  the  treatment  is  being 
planned. 

Just  normal  structure,  just  normal  blood,  flowing  freely  under 
normal  pressure,  just  normal  innervation,  are  necessary  to  enable 
the  organs  of  elimination  to  throw  out  from  the  system  those  sub- 
stances which  they  are  capable  of  handling. 

So  the  treatment  for  chronic  poisoning  includes  the  correction 
of  structural  perversions  which   prevent  normal  activity  of  the 

322 


ALCOHOL  323 

eliminating  organs;  such  washings  of  the  colon  as  may  be  neces- 
sary to  remove  the  accumulating  feces ;  such  increased  drinking  of 
water,  and  of  fruit  and  vegetable  juices,  and  such  eating  of  good 
food,  as  may  be  necessary  in  order  to  provide  fluids  and  foods 
for  the  body.  Fresh  air,  in  abundance,  exercise  in  the  open  air, 
and  all  hygienic  conditions,  enable  the  elimination  processes  to  go 
on  more  rapidly  than  could  be  the  case  under  unhygienic  conditions. 


ALCOHOLISM 

Alcoholism  is  the  term  used  to  designate  the  physical  and 
mental  phenomena  induced  by  the  use  of  alcoholic  liquors,  and 
occurring  in  several  distinct  forms. 

Etiology.  Heredity,  local  and  family  custom,  the  use  of 
alcoholic  and  other  drugs  in  infancy;  occupation,  those  handling 
liquors;  social  association;  and  the  physical  depletion  due  to 
improper  food,  the  use  of  other  drugs,  worry  and  overwork,  all 
tend  to  establish  the  habit. 

Morbid  changes  are  numerous  and  afifect  nearly  every  portion 
of  the  body;  including  chronic  nasal,  oral,  esophageal,  gastric  or 
gastro-intestinal  catarrh;  fatty  and  cirrhotic  liver;  arteriosclerosis, 
dilatation  of  the  heart;  and  interstitial  nephritis.  The  nervous 
system  is  especially  liable  to  suffer.  Peripheral  and  multiple  neu- 
ritis, pachymeningitis,  myelitis,  apoplexy,  and  degenerative  brain 
lesions  occur.    The  germ  cells  in  both  sexes  are  affected. 

Certain  peculiar  forms  of  alcoholism  may  be  mentioned.  The 
use  of  the  cheaper  grades  of  whisky  leads  to  poisoning  with  wood 
alcohol,  in  which  blindness  and  visual  disturbances  are  common. 
Cheap  drinks  are  sometimes  mixed  with  other  poisons,  each  of 
which  may  modify  the  picture  presented  by  uncomplicated  alco- 
holic poisoning. 

Women  sometimes  use  Cologne  water,  or  other  alcoholic 
extracts,  for  stimulation.  A  warm  bath,  perfumed  by  any  of 
these,  may  give  enough  inhaled  alcohol  to  produce  recognizable 
(effects.  Alcohol  used  in  the  arts  and  the  trades  may  give  o(ff 
fumes  enough  to  result  in  poisoning.  Jamaica  ginger  is  taken  as 
a  drug,  but  really  for  its  alcohol ;  the  use  of  patent  medicines  con- 
taining alcohol  is,  fortunately,  diminishing. 

Absinthe  is  a  peculiarly  deadly  liquor,  made  from  wormwood 
and  alcohol.  It  gives  greater  exhilaration  than  alcohol  alone,  with 
more  profound  depression  and  more  violent  delirium.  Its  effects 
upon  the  nervous  system  are  more  profound  than  are  those  of 
alcohol  in  other  forms. 

Acute  Alcoholism  (Temulentia ;  drunkenness  or  alcoholic  intox- 
ication). The  ordinary  forms  do  not  often  come  under  treatment 
unless   at   a   receiving   hospital.     Alcoholic   coma    (dead   drunk) 


324  DRUG  POISONING 

is  important  as  it  may  be  confused  with  more  serious  conditions. 
The  breathing  is  stertorous,  the  face  bloated  and  congested,  the 
lips  swollen  and  purplish,  the  pulse  feeble  and  slow,  the  temples 
depressed,  the  skin  cold  and  clammy,  the  pupils  dilated;  frequently 
control  of  the  sphincters  is  lost.  It  is  too  often  confused  with 
cerebral  hemorrhage,  uremia,  brain  injury  and  coma  from  other 
causes. 

Von  Wedekind's  test  is:  "By  simple  pressure  on  the  supra- 
orbital notches  with  a  steadily  increasing  force  one  may,  with 
certainty  of  success,  bring  an  unconscious  alcoholic  to  his  senses, 
•and  thus  differentiate  between  alcoholic  and  other  comas." 

Treatment.  Emergency  treatment  is  given,  according  to  cir- 
cumstances. Wash  out  the  stomach.  Hot  coffee  may  be  given 
by  the  stomach  tube.  Alternate  hot  and  cold  applications  should 
be  made  to  the  skin.  Vigorous  stimulation  of  the  upper  thoracic^ 
area  is  necessary  if  the  heart  and  respiration  are  failing.  If  the 
diagnosis  is  at  all  doubtful,  physical  diagnosis,  urinalysis,  and  blood, 
retinal  and  other  examinations  should  be  made  to  reveal  the  true 
condition. 

The  odor  of  alcohol  upon  the  breath  is  of  no  value  in  diagnosis ; 
abstemious  men  may  drink  when  symptoms  of  coma  appear. 
Coma  cases  should  be  considered  serious  until  a  diagnosis  of 
alcoholism  is  demonstrated.  The  common  view  that  a  drunk  man 
is  immune  to  abuse  is  responsible  for  much  injury.  More  humane 
care  of  the  drunk,  followed  by  further  measures  for  cure  of  the 
habit  would  work  almost  as  much  of  a  revolution  as  did  the  estab- 
lishment of  similar  measures  in  the  care  of  the  insane. 

Mania  a  Potu  (Crazy  drunk)  is  a  state  of  transitory,  acute, 
often  homicidal  mania  which  occasionally  replaces  ordinary  intoxi- 
cation in  those  of  neurotic  temperament.  It  must  be  distinguished 
from  acute  mania.  Wash  stomach  and  colon,  unless  vomiting  has 
been  free  and  has  ceased.  Give  much  hot  water,  weak  tea,  lem- 
onade, and  diluted  fruit  juices.  Restraint  may  be  necessary,  but 
must  be  made  as  nonirritating  as  possible.  Chloroform  may  be 
required  in  violent  cases,  when  restraint  is  difficult.  The  parox- 
ysm is  short,  and  terminates  in  stupor,  from  which  the  patient 
awakens  with  no  memory  of  his  storm. 

Heavy  extension  of  the  neck,  with  the  sudden  correction  of 
whatever  lesions  may  be  found,  employing  strong  movements,  has 
been  known  to  terminate  suddenly  the  paroxysm,  and  produce 
sleep.  After  an  attack,  the  knowledge  of  things  done  and  the 
dangers  incurred  during  the  paroxysm  may  serve  good  educa- 
tional purpose. 

Dipsomania  (Oinomania)  is  a  true  mental  disease  manifested 
by  periodic  attacks  of  excessive  alcoholic  indulgence  or  this  may 
be  replaced  by  other  irresistible  desires  such  as  lead  to  the  com- 


ALCOHOL,  325 

mission  of  crimes  and  the  gratification  of  depraved  appetites.  Dur- 
ing the  intervals  the  patient  may  neither  wish  nor  crave  alcohol. 
Imbecility  and  dementia  frequently  follow. 

Chronic  Alcoholism.  After  months  or  years  of  alcohol  using 
with  no  serious  effects,  the  symptoms  begin  with  nausea  or  a 
feeling  of  sinking  in  the  morning,  soon  followed  by  morning 
vomiting.  The  tongue  is  furred  and  tremulous,  the  appetite  fails, 
and  the  bowels  are  first  constipated,  then  loose.  Later,  the  hands 
become  tremulous,  muscular  power  is  diminished  and  the  gait  may 
become  ataxic.  The  patellar  reflex  is  lost.  Insomnia  or  disturbed 
sleep  is  common.  Sensory  disturbances  of  nearly  every  kind  are 
found  in  different  individuals.  The  mental  state  is  expressed  by 
Korsakoff's  syndrome — weak  memory,  weak  morals,  weak  will. 
Hallucinations  of  sight  and  hearing  may  arise.  Some  cases  end 
in  dementia,  others  in  cirrhosis  of  the  liver  or  kidneys,  cardiac 
failure  or  meningitis. 

Delirium  Tremens  occurs  in  habitual  drinkers  and  may  be 
excited  by  injury,  shock,  exposure,  prolonged  debauch,  abstinence 
from  proper  food,  or  in  the  course  of  acute  diseases.  The  onset  is 
accompanied  by  irritability,  restlessness  and  disturbed  sleep. 
Tremor  is  marked  especially  of  the  small  muscles  of  the  hands, 
face,, and  tongue.  The  patient  talks  to  himself  or  answers  imag- 
inary voices.  In  a  day  or  so,  visual  hallucinations  of  moving  ani- 
mals appear  from  which  he  tries  to  escape.  Illusions  of  smell  and 
hearing  may  also  appear.  Paresthesias  of  various  sorts  may  be 
present.  Noisy  delirium  may  appear.  Perspiration  is  abundant; 
the  temperature  is  somewhat  elevated,  rarely  above  103°  F. ;  the 
pulse  is  rapid  and  soft  and  easily  compressible.  There  is  complete 
insomnia.  Sleep  usually  returns  about  the  third  to  the  fifth  day, 
from  which  the  patient  awakens  sane  and  hungry  and  conval- 
escence begins. 

Should  the  delirium  subside  into  a  low  muttering  type,  with  sub- 
sultus  tendinum,  dry  cracked  tongue,  regurgitation  of  a  dark 
brownish  and  bilious  matter,  an  early  death  is  to  be  expected,  in 
coma,  convulsions  or  from  exhaustion. 

The  urine  is  often  albuminous  and  contains  casts,  kidney  cells, 
blood.  The  blood  may  show  leucocytosis  at  the  height  of  delirium 
tremens. 

The  four  diagnostic  points  of  chronic  alcoholism  are :  insomnia, 
morning  vomiting,  muscular  tremor,  causeless  mental  restlessness. 
It  is  to  be  distinguished  from  general  paralysis,  disseminated  scle- 
rosis, paralysis  agitans,  locomotor  ataxia,  cerebral  and  spinal  soft- 
ening, epilepsy,  dementia  chronica,  and  nervous  dyspepsia. 

All  forms  of  chronic  alcoholism  require  scientific  institutional 
care  to  build  up  the  patient  physically  and  morally. 


326  DRUG  POISONING 

Prognosis.  Acute  alcoholism  has  good  outlook  if  the  patient  is 
manageable.  Chronic  alcoholism  tends  to  shorten  life  by  pro- 
ducing morbid  changes  in  the  vital  organs.  Delirium  tremens 
produces  liability  to  heart  failure  or  death  through  a  gradually  deep- 
ening coma.  Acute  lobar  pneumonia  is  a  very  fatal  complication 
in  any  form  of  alcoholism. 

MORPHINISM 

(Morphine  habit;  morphinomania) 

Morphinism  is  a  term  used  to  designate  the  phenomena  follow- 
ing the  habitual  use  of  opium,  especially  of  its  derivative,  morphia. 

The  habit  usually  originates  in  use  for  the  relief  of  pain.  The 
ordinary  narcotic  effect  is  succeeded  by  euphoria  and  exaltation, 
with  quickening  of  the  mental  processes;  this  lasts  for  a  limited 
time  and  is  in  turn  followed  by  profound  depression.  Brain  work- 
ers are  especially  liable  to  fall  victims  of  the  habit  which  has  been 
greatly  on  the  increase  in  this  country.  Doctors  of  medicine  and 
nurses  are  frequent  victims. 

Diagnosis.  The  victim  usually  presents  a  characteristic  appear- 
ance; has  a  sallow,  hard,  wrinkled  skin,  is  prematurely  aged,  ema- 
ciated and  of  cachectic  appearance.  Variable,  occasional  colic, 
alternating  constipation  and  diarrhea,  chills  followed  by  profuse 
sweating,  variable  fever,  itching  of  the  skin,  restlessness,  exagger- 
ated sensibilities,  disturbed  sleep  or  insomnia,  are  the  usual  symp- 
toms. The  reflexes  are  at  first  increased ;  later  "abolished.  The 
pupils  are  contracted  just  after  a  dose  and  dilated,  sometimes 
unequally,  in  the  intervals.  Patients  are  remarkably  untruthful 
and  ingenious  in  concealing  the  habit. 

If  a  patient  sTiows  evidences  of  malnutrition  without  cause,  has 
some  fever,  pruritis,  and  the  appearance  above  indicated,  it  is  well 
to  examine  the  urine  or  washings  from  the  stomach  for  morphia. 
Death  may  be  due  to  progressive  asthenia,  intercurrent  disease,  or 
to  accidental  or  intentional  overdose. 

Acute  Opium  Poisoning  (Opium  narcosis)  is  due  to  an  over- 
dose and  may  occur  in  habitues  as  well  as  with  nonusers.  The 
first  symptoms  appear  within  five  to  forty  minutes.  In  subjects 
of  alcoholic  mania,  it  may  be  followed  by  sudden  and  complete 
coma.  The  onset  is  usually  abrupt;  the  patient  may  be  talking 
one  moment,  the  next  be  profoundly  unconscious ;  the  jaws,  at 
first  fixed,  are,  later,  relaxed.  The  pin-point  pupils  do  not  react 
to  light,  and  sensation  is  lost  in  the  cornea. 

The  respiration  drops  to  10,  perhaps  4,  per  minute;  the  heart 
action  is  weak,  the  pulse  feeble  and  well  nigh  imperceptible,  the 
face  is  pale,  sometimes  cyanotic,  the  skin  is  dry  or  bathed  in  per- 
spiration.   The  coma  is  profound.    When  partially  aroused,  speech 


MORPHINE  327 

is  incoherent  and  the  patient  relapses  quickly.  There  is  retention 
of  urine  and  later  vesical  tenesmus.  The  tongue  may  drop  back 
into  the  pharynx.  Respiration  is  stertorous  and  the  cheeks  flap. 
Under  successful  treatment,  the  coma  lessens,  the  color  and 
pulse  improve.  Relapses  are  frequent  and  days  may  elapse  before 
the  patient  is  out  of  danger.  Diagnosis  must  be  made  from  coma 
of  uremia,  alcohol,  sunstroke,  and  cerebral  hemorrhage. 

Morphia  may  be  isolated  from  the  urine  and  from  the  stomach 
contents. 

Treatment.  In  opium  narcosis,  the  main  thing  is  to  prevent 
coma,  hence  walking  the  patient,  and  elimination  by  all  possible 
avenues,  hot  and  cold  sprays,  sharp  blows  upon  the  skin,  any- 
thing to  keep  him  awake,  are  indicated.  Give  strong,  stimulating 
movements  to  the  cardiac  areas ;  raise  the  ribs  and  give  shaking 
movements  to  the  lower  part  of  the  thorax ;  extend  the  cervical 
spine.  If  convenient,  electric  stimulation  of  the  skin  may  help.  As 
much  strong  hot  coflfee  as  the  patient  can  swallow  helps  to  over- 
come the  narcosis.  When  the  breathing  becomes  regular  and  the 
heart  strong,  he  may  rest,  but  not  sleep  for  several  hours.  For  two 
days  he  must  be  watched.  Toxic  symptoms  may  appear  at  any 
time  for  several  days. 

Chronic  morphinism  must  receive  institutional  care,  as  a  rule. 
The  habit  depends  partly  upon  the  existence  of  an  antibody  which 
results  from  the  use  of  the  drug,  for  which  the  morphine  itself  is 
an  antidote.  In  order  to  rid  the  system  of  this  poisonous  anti- 
body, it  is  necessary  to  promote  elimination  in  every  possible 
manner.  This,  with  the  fact  that  absolute  control  of  the  patient 
is  necessary  to  keep  the  drug  away  from  him,  at  first,  renders  the 
home  care  of  such  patients  most  difficult. 

It  is  best  to  take  the  drug  away  at  once,  in  all  but  a  very  few 
badly  depleted  persons,  and  from  them  within  a  few  days.  There 
is  not  apt  to  be  any  appetite,  and  food  is  denied,  anyway.  Free 
drinking  of  water  or  diluted  fruit  juice  is  necessary,  the  colon 
washed,  sometimes  the  stomach,  if  nausea  and  vomiting  are  bad ; 
very  heavy  treatment  for  the  rigidity  of  the  thorax  and  the  lower 
thoracic  spir>e  are  helpful.  Baths,  hot  and  cold  sprays,  massage, 
should  keep  the  patient  occupied  with  something  practically  all  the 
time  during  his  wakefulness.  It  may  be  necessary  to  use  some 
'purgative  drug  at  first,  this  is  to  be  avoided  if  possible.  The 
patient  must  not  be  permitted  access  to  the  drug  until  his  entire 
body  is  clean  and  strong,  and  he  has  shown  evidences  of  recu- 
perated will  power  as  well  as  body  strength. 

Prognosis.  Few  habituated  morphinists  recover,  alone.  Those 
who  receive  proper  care  may  overcome  the  habit  permanently. 


328  DRUG  POISONING 

COCAINISM 

The  cocaine  habit  is  frequent,  especially  in  the  southern  states. 
It  is  used  by  morphinists,  after  the  morphine  has  become  too 
expensive  or  hard  to  procure.  Its  use  is  indicated  by  emaciation 
and  mental  disturbances.  Moral  perversion  develops  rapidly. 
There  is  frequently  a  sensation  of  sand  under  the  skin.  If 
unchecked  it  leads  to  melancholia  or  mania. 

Its  treatment  is  even  more  difficult  than  the  morphine  habit, 
with  which  it  is  frequently  associated.  Its  use  by  boys  who  show 
other  signs  of  degeneracy  makes  the  prognosis  still  more  serious. 
It  is  rather  widely  used  among  artistic  and  literary  people  of  neu- 
rotic type,  and  in  these  it  terminates  suddenly  with  marked  mental 
and  nervous  disturbances,  total  inefficiency,  and  death  after  a 
variable  period  of  invalidism. 

LEAD  POISONING 

(Plumbism;  saturnism) 

Lead  poisoning  is  a  common  occupational  disease,  the  lead 
entering  the  system  by  deglutition,  inhalation,  and  absorption 
through  the  skin.  It  is  eliminated  principally  by  the  bowels  and 
kidneys. 

The  morbid  changes  affect  the  whole  body  especially  the  nerv- 
ous and  the  circulatory  systems,  and  the  blood. 

Acute  Lead  Poisoning  usually  results  from  lead  acetate  or  sub- 
acetate  being  swallowed  by  mistake.  The  chief  symptoms  are 
sense  of  constriction  in  the  throat  and  at  pit  of  stomach,  crampy 
pains  around  the  umbilicus,  and  stiffness  of  the  abdominal  muscles. 

Treatment  is  sodium  sulphate,  magnesium  sulphate  or  alum 
dissolved  in  water  to  form  the  insoluble  lead  sulphate.  Emesis  is 
indicated. 

Chronic  Lead  Poisoning.  Among  the  first  symptoms  are 
anorexia,  constipation,  a  metallic  taste  in  the  mouth  mornings, 
tendency  to  headache,  fetid  breath  and  coated  tongue.  The  patient 
becomes  morose,  apathetic,  and  irritable.  Saturnine  cachexia 
appears,  the  face  becoming  progressively  pale  and  sallow.  The 
blue-black  line,  the  specific  symptom,  is  seen  at  the  margins  of 
the  gums ;  if  no  teeth,  no  blue  line. 

Lead  Colic  (Painter's  colic;  Devonshire  colic;  colica  pictonum). 
This  is  of  sudden  onset  and  is  briefly  outlined  as  follows: 
There  may  be  acute  or  superficial,  paroxysmal  pain  centered  about 
the  umbilicus  accompanied  by  tenderness  and  more  severe  on  one 
side;  or,  constant  deep-seated  pain  with  retracted  abdomen  and 
constipation.  The  pulse  is  slow,  of  high  tension,  and  sometimes 
unequal  in  the  two  wrists.     Vomiting  is  frequent.     The  attack 


LEAD  329 

usually  passes  off  in  about  three  days  but  may  be  frequently 
repeated. 

Lead  Paralysis  (Paralysis  saturnina;  lead  palsy).  This  fre- 
quently appears  as  a  bilateral  wrist-drop  in  which  the  extensor 
muscles  supplied  by  the  musculo-spiral  nerve  to  the  fingers  and 
wrists  are  affected,  the  hands  hanging  flabbily  at  the  sides.  The 
supinator  longus  and  extensor  metacarpi  pollicis  also  supplied 
from  the  musculo-spiral  usually  escape. 

Ankle-drop  (Peroneal  paralysis)  may  be  present  instead  of 
the  brachial  variety.  Occasionally  both  are  seen  in  the  same 
patient.  Paralysis  of  the  upper  arm  muscles  and  Aran-Duchenne 
type  of  paralysis  are  less  frequent.  In  all  forms,  muscular  atrophy 
is  rapid  and  the  reaction  of  degeneration  present.  Pain  is  slight 
or  absent. 

Cerebral  symptoms  may  appear,  as  optic  neuritis,  delirium  with 
hallucinations,  tremor,  and  headache. 

Encephalopathy  Saturnina  is  less  common.  It  is  most  frequent 
in  women.  It  is  marked  by  severe  headache  followed  by  either 
delirious,  convulsive,  or  comatose  symptoms. 

The  delirium  is  at  first  tranquil,  becoming  later  furious  and 
paroxysmal,  with  intervals  of  quiet.  Later,  true  sleep  follows 
with  complete  restoration,  or  coma,  ending  in  death.  Rarely, 
insanity  and  amaurosis  may  be  permanent. 

Arthralgia  (Arthralgia  saturnina)  is  not  uncommon.  There 
are  often  severe,  tearing,  burning,  paroxysmal  pains  with  exacer- 
bations and  remissions,  present  in  the  joints  and  contiguous  mus- 
cles. The  knee  is  most  commonly  affected.  Gout  is  frequent 
among  lead  workers. 

Pregnant  women  abort  or  have  still-births.  If  children  are 
born  alive,  they  usually  succumb  in  infancy. 

Lead  poisoning  may  result  in  contracted  kidney,  hypertrophy 
of  the  heart,  and  arteriosclerosis. 

Lead  may  be  isolated  from  the  urine  in  minute  quantities. 
Hematoporphyrin  has  also  been  found. 

The  blood  shows  a  moderate  grade  of  anemia.  The  red  cells 
do  not  usually  fall  below  50%  but  show  basophilic  granular 
degeneration  of  large  numbers  of  cells  and  nucleated  reds  are 
constantly  present.  There  may  be  a  slight  increase  in  the  diameter 
of  the  reds ;  megaloblasts  are  sometimes  seen  and  their  rigidity 
is  increased.    The  white  cells  are  practically  normal. 

Treatment.  Lead  colic  requires  rest  in  bed,  hot  applications, 
enemas  and  the  usual  treatment  for  colic.  Change  of  occupation 
is  very  desirable  in  chronic  lead  poisoning  preferably  to  some 
active  outdoor  pursuit.  Paralyzed  limbs  require  treatment  at  the 
spinal  source  of  nerve   supply  and  local   treatment  to  keep  the 


330  DRUG  POISONING  ' 

circulation  active.  Saturnine  encephalopathy  is  best  treated  by- 
securing  free  elimination  as  rapidly  as  possible.  In  rare  and  excep- 
tionally severe  cases,  lumbar  puncture  may  be  necessary. 

Prophylaxis.  All  lead  works  should  teach  their  employees  the 
dangers  of  uncleanliness,  should  provide  means  of  thorough  clean- 
liness and  should  use  every  precaution  possible  to  keep  the  amount 
of  lead  dust  at  a  minimum.  The  employees  should  keep  their 
hands  and  finger  nails  clean,  bathe  frequently,  and  use  respirators 
when  it  is  necessary.  Painters,  must  be  very  careful  about  eating 
with  unwashed  or  poorly  washed  hands. 

MERCURIALISM 

(Chronic  mercurial  poisoning) 

This  is  chronic  poisoning,  by  mercury,  of  persons  who  may  be 
susceptible  to  its  effects.  Its  presence  from  the  use  of  mercury 
as  a  drug  is  diminishing  rapidly,  on  account  of  the  less  frequent 
use  of  calomel  in  medicine.  Those  who  work  in  smelters,  or 
mines  of  quicksilver,  or  who  make  thermometers,  mirrors,  certain 
pigments,  etc.,  breathe  in  the  vapor,  even  should  their  hands  be 
kept  scrupulously  clean.  Mercury  is  still  used  in  drugs,  and 
thus  a  few  cases  are  yet  found,  of  poisoning  therefrom. 

Diagnosis.  It  may  be  difficult  to  distinguish  between  this 
poisoning  and  late  syphilis,  especially  since  the  drug  is  used  in 
treating  the  infection.  The  symptoms  of  mercurialism  include 
salivation  and  stomatitis,  loosening  of  the  teeth,  softening  of 
gums,  with  ulceration  and  necrosis  of  the  jaw,  brittle  nails,  brittle 
and  falling  hair,  anemia,  gastrointestinal  disturbances,  tremor, 
aphasia,  paralysis,  confusional  insanity,  various  sensory  disturb- 
ances, including  severe  pains  in  the  legs  and  in  other  parts  of  the 
body.^ 

The  treatment  is  chiefly  the  removal  of  the  possibility  of  further 
poisoning.  The  drug  is  eliminated  slowly  from  the  body,  and 
structural  lesions  never  are  repaired.  The  usual  treatment  for 
chronic  poisoning  is  to  be  adapted  to  the  condition  of  the  patient 
on  examination. 

Prognosis  depends  upon  the  amount  of  structural  injury.  Recov- 
ery is  slow,  at  the  best. 

ARSENICISM 

(Chronic  arsenic  poisoning) 

This  is  a  slow  poisoning  by  arsenic.  It  is  taken  into  the  body 
as  a  drug,  especially  for  its  effect  upon  the  complexion,  and  in  the 
medical  treatment  of  anemia;  it  may  be  an  occupational  dis- 
ease, as  in  those  who  work  in  smelters,  dyers^  makers  of  wall 


HBADACHB  MBDICINBS.  331 

paper,  rugs ;  or  who  embalm  animals  or  prepare  hides  and  furs,  or 
who  use  arsenic  in  their  work  in  any  way.  Those  who  live  in 
poorly  ventilated  rooms  whose  walls,  rugs,  and  ornaments  contain 
arsenic  may  sufifer  arsenic  poisoning — this  form  is  less  commonly 
found  than  before.  Children  who  drink  the  milk  from  cows  that 
feed  upon  the  grass  wet  by  the  rain,  in  air  polluted  by  smelters, 
may  suffer  from  arsenic  poisoning. 

Diagnosis.  Arsenic  poisoning  should  be  suspected  when  the 
following  symptoms  appear :  a  gradually  increasing  neuritis,  affect- 
ing the  legs  first ;  mild  and  constant  catarrhal  gastritis ;  headache 
and  vertigo ;  mild  nephritis.  A  slow  anemia,  with  waxy  skin, 
bright  eyes,  with  little  or  no  loss  of  weight  are  usually  present  in 
varying  degrees,  and  should  lead  to  a  urinary  test  for  arsenic;  this 
may  have  to  be  several  times  repeated  before  the  positive  reaction 
is  secured. 

Treatment.  The  immediate  removal  of  the  arsenic  is  indicated, 
though  this  may  be  followed  by  symptoms  of  increased  intoxica- 
tion. Later  treatment  to  provide  for  increased  nutrition  may  be 
necessary. 

HEADACHE  MEDICINES 

Many  very  different  medicines  for  the  relief  of  headache  and 
other  pain  are  in  constant  use.  Their  effects  are  variable,  but 
mostly  include  low  blood  pressure,  erratic  and  fleeting  pains  in 
the  nerves  and  muscles,  hypersensitiveness  of  the  skin  and  deeper 
tissues,  and  diminished  powers  of  resistance  to  the  ordinary  emer- 
gencies of  life.  Mental  effects  are  mostly  included  in  an  increasing 
loss  of  attentiveness  and  memory,  and  progressive  inability  to 
endure  any  pain  or  discomfort. 

The  habit  is  extremely  obstinate.  The  effects  upon  the  heart, 
the  nervous  system  or  the  stomach,  according  to  the  particular 
nostrum  affected,  may  cause  influenza,  pneumonia,  or  other  dis- 
ease to  be  speedily  fatal.  Comfort  and  efficiency  are  lowered 
throughout  life,  and  much  suffering  ultimately  results  from  this 
pernicious  habit. 

It  is  sometimes  possible  to  recognize  these  drugs  by  urinalysis. 
A  deep  purple,  blue  or  red  color  appears  upon  the  addition  of  a 
few  drops  of  a  saturated  ferric  chloride  solution  to  the  urine.  A 
negative  reaction  has  no  significance;  and  there  are  many  drugs 
which  may  give  a  positive  reaction. 


CHAPTER  XXXII 
FOOD  POISONING 

GENERAL  DISCUSSION 

Poisons  which  enter  the  body  with  foods,  or  foods  which 
as  the  result  of  bacterial  or  other  changes  become  transformed  into 
poisons,  are  receiving  more  than  usual  attention  just  now,  since 
the  comparative  prevalence  of  pellagra  is  recognized. 

The  chemical  differences  between  foods  and  poisons  are  often 
very  slight.  The  bacteria  which  invade  food  may  change  its 
molecules  from  food  to  poison,  rarely  without  changing  recog- 
nizably the  taste  or  the  appearance.  Bacteria  may  be  taken  into 
the  body  with  the  food,  and  acting  upon  them  in  the  intestinal 
tract,  may  form  poisonous  compounds  slowly,  which  are  thus 
enabled  to  be  absorbed  into  the  blood  stream  without  arousing 
inflammatory  reaction,  and  cause  death.  Other  materials  are 
acted  upon,  either  by  autolytic  enzymes,  or  by  perverted  digestive 
juices,  in  such  a  way  as  to  become  poisonous.  It  is  not  possible 
to  deny  absolutely  that  these  cases  are  not  really  due  to  bacterial 
action,  but  there  are  several  reasons  for  supposing  that  the  reaction 
is  sometimes  due  to  an  enzyme  rather  than  to  cellular  activity. 

Other  substances  which  are  foods  for  one  person  may  be  poison 
for  another.  Personal  idiosyncrasies  cover  many  puzzles.  There 
are  yet  other  instances  in  which  the  too  constant  use  of  some 
single  class  of  food,  itself  desirable,  perhaps  necessary,  results  in 
disturbed  metabolism  and  finally  symptoms  of  intense  poison- 
ing. In  many  diseases,  especially  of  the  digestive  tract,  it  is  prob- 
able that  the  place  in  the  symptom  complex  due  to  the  absorption 
of  perverted  food  molecules  is  a  very  large  one;  the  diseases  and 
deaths  due  to  the  absorption  of  poisonous  compounds  from  foods 
at  all  times  are  probably  more  than  we  now  realize. 

Diagnosis.  The  recognition  of  acute  poisoning  by  food  must 
be  based  upon  the  symptoms,  plus  the  history.  Speedy  evacuation 
of  the  entire  digestive  tract  is  urgent,  and  this  must  be  secured 
in  any  way  that  does  not  injure  the  membranes.  It  must  not  be 
forgotten  that  an  inftamed  membrane  may  take  up  more  poison 
than  a  normal  membrane.  There  is  a  protective  action  of  nor- 
mal intestinal  membrane,  for  certain  poisons,  which  may  be 
destroyed  by  too  urgent  purgation.  If  the  material  is  still  in  the 
stomach,  the  stomach  tube  may  remove  it  completely ;  later,  pur- 
gative medicines  that  are  least  irritating  should  be  used.  The 
constant  and  free  use  of  the  enema  is  indicated  in  all  cases;  prac- 

332 


PELLAGRA  333 

tically  no  absorption  takes  place  in  the  lower  bowel,  and  the  con- 
stant removal  of  this  material  promotes  peristalsis  of  the  upper 
part  of  the  digestive  tract. 

After  the  poison  has  been  absorbed,  it  must  be  removed  by 
liver,  kidneys,  lungs  and  skin.  Circulation  must  be  kept  active 
by  stimulating  manipulations,  hot  and  cold  spray,  friction  of  the 
skin,  etc.  Body  heat  must  be  artificially  maintained  in  some  cases 
— friction,  hot  coverings,  packs  must  be  freely  employed.  These 
also  promote  oxidation  and  elimination.  The  patient  should  drink 
very  freely  of  hot  or  cold  water;  if  he  is  unable  to  do  this,  sterile 
normal  salt  injected  into  the  subcutaneous  tissues  is  absorbed  into 
the  blood  stream,  eliminated  by  the  kidneys,  and  thus  much  poison 
is  carried  away. 

When  the  intestinal  tract  is  cleaned,  the  systemic  symptoms 
may  be  severe.  Fever  is  combatted  with  the  ordinary  methods — 
suboccipital  and  mid-dorsal  inhibition;  baths;  collapse  requires 
stimulating  manipulations  affecting  the  heart  centers,  raising  the 
ribs,  stimulating  the  liver  and  spleen,  and  plenty  of  hot  drinks  and 
warm  clothing,  w^th  hot  water  bottles.  Convulsions  may  need 
the  neutral  bath,  friction,  rarely  chloroform  inhalations;  paras- 
thesias  and  paralyses  do  not  require  immediate  attention. 

After  the  acute  attack  is  over,  there  probably  remains  some 
poisonous  material  in  the  system,  and  the  cells  of  the  body  have 
been  injured  by  the  poisoning.  In  order  to  promote  the  most 
complete  and  rapid  recovery,  whatever  structural  changes  may 
have  been  produced  from  the  illness,  or  which  may  have  been 
present  before,  should  be  corrected.  Free  drinking  of  water  pro- 
motes the  elimination  of  the  remaining  poison.  The  intestinal 
tract  may  have  suffered  from  the  violent  purgation  and  emesis; 
rest  and  bland  foods  are  best  for  a  few  days.  As  soon  as  conditions 
permit,  the  patient  should  go  upon  a  very  largely  cellulose  diet; 
this  fills  and  stimulates  the  intestines ;  carries  no  putrefiable  mate- 
rial, and  little  that  is  fermentable.  The  digestive  secretions  receive 
normal  stimulation,  the  intestines  are  cleaned,  and  conditions  per- 
mit rapid  recovery.  A  certain  amount  of  nutrition,  and  especially 
the  inorganic  salts  in  organic  compounds,  is  given  by  this  class  of 
foods,  and  they  are  excellent  to  use  under  all  toxic  conditions. 

PELLAGRA 

(Alpine  scurvy;  Italian  leprosy;  maidismus) 
Pellagra  is  a  disease  due  to  some  unknown  cause.  Several 
bacteria  and  protozoa  have  been  described.  Lack  of  vitamins  seems 
important,  as  is  also  intoxication  from  an  unbalanced  diet,  chiefly 
carbohydrate,  and  often  more  or  less  injured  by  fermentation.  It 
appeared  first  in  those  who  eat  too  much  stale  and  sour  polenta 
in   Italy;  later  it  appeared  in  this  country,   among  those   with 


334  FOOD  POISONING 

various  unbalanced  diets — excess  of  cotton  seed  oil;  excess  of 
sugar  cane;  generally  a  lack  of  fresh  nitrogenous  foods  is  char- 
acteristic. Cases  appear  in  asylums,  orphanages,  prisons,  when 
the  diet  is  too  greatly  restricted  and  too  greatly  carbohydrate. 
Insanitary  conditions  are  fairly  constant,  though  a  few  cases  have 
been  reported  among  people  of  fairly  good  homes. 

Diagnosis.  This  rests  almost  exclusively  upon  the  symptoms. 
The  pathognomonic  triad  includes  obstinate  diarrhea  with  marked 
cachexia ;  eruption  recurring  each  spring,  mostly  on  exposed  areas, 
exacerbated  in  sunshine;  and  melancholia  often  of  the  excitable 
type,  with  tendency  to  suicide  by  drowning. 

The  blood  is  of  chlorotic  type,  with  leucopenia  and  a  relative 
excess  of  large  mononuclears.  No  characteristic  symptoms  are 
found  in  the  urine,  nor  upon  physical  examination. 

"The  prodromal  stage  varies  in  length,  and  is  marked  by  clinical  symptoms 
that  appear  in  any  disease  of  microbic  origin — general  malaise,  headache,  lan- 
guor, and  mild  digestive  disturbances.  One  of  the  earliest  symptoms  is  an 
erythema  that  usually  first  appears  on  the  hands  and  feet  and  that  is  particu- 
larly severe  on  exposed  parts  of  the  body.  The  eruption  comes  on  suddenly, 
and  manifests  itself  as  a  dark,  or  bright  red,  diffuse  erythema.  This  may  be  a 
simple  hyperemia  that  will  disappear  on  pressure,  or  a  livid  congestion  that 
may  become  hemorrhagic.  The  skin  swells,  burns,  and  itches  severely.  The 
rash  lasts  about  two  weeks  and  is  followed  by  desquamation  of  the  epidermis, 
first  in  large  flakes  and  then  in  branny  scales.  The  skin  is  left  pigmented  and 
somewhat  thickened,  conditions  that  with  repeated  annual  attacks  of  the  disease 
are  increased.  Following  four  or  five  such  recurrences,  the  skin  atrophies  and 
becomes  thin,  loose,  dry,  wrinkled,  and  pigmented.  The  area  affected  by  these 
changes  also  increases  as  years  go  on,  until  finally  the  entire  body  may  become 
involved.  The  peculiar  distribution  of  the  lesion  is  very  characteristic,  and 
seems  to  point  to  the  sun  as  an  exciting  cause,  in  that  the  exposed  parts  of  the 
body — backs  of  hands,  forearms,  face,  neck,  and  dorsum  of  the  feet  are  particu- 
larly affected.  Sensation  is  disturbed.  Patients  describe  their  feelings  as  that 
of  flames  surrounding  them,  of  hot  or  cold  water  being  poured  over  their 
heads  or  backs;  others,  of  prickly  sensations,  formication,  etc.  In  passing,  it 
may  be  of  interest  to  note  that  on  account  of  this  burning  sensation,  water  has 
a  peculiar  fascination  for  the  pellagrins.  They  like  its  feeling  on  their  skin; 
they  gaze  at  it ;  yet  they  are  lured  on  by  the  spell  in  which  it  holds  them 
until  overcome  by  nausea  and  vertigo  they  become  the  victims  of  its  charm. 
With  others  the  sight  of  water  seems  to  cause  a  vertigo  that  temporarily  over- 
whelms them.  So  strong  is  this  influence  on  pellagrins  that  statistics_from 
pellagrinous  districts  show  a  striking  percentage  of  deaths  by  drowning.  The 
extreme  sensitiveness  of  the  skin  may  induce  a  spasm  from  so  slight  an  exciting 
cause  as  a  breath  of  air  or  a  ray  of  light.  Most  victims  suffer  pain  of  varying 
intensity  in  some  parts  of  the  body. 

Later  Symptoms — The  disease  appears  in  the  spring,  lasts  until  midsummer, 
disappears — perhaps  completely — during  the  winter,  only  to  reappear  the  next 
spring  with  increased  severity.  After  two  or  three  years  all  of  the  constitutional 
symptoms  become  exaggerated.  The  tongue  becomes  red  and  dry,  there  is  a 
burning  sensation  in  the  mouth,  swallowing  is  painful,  diarrhea  increases,  and  the 
patient  emaciates  rapidly.  There  are  severe  headache  and  backache,  tenderness 
over  the  dorsal  vertebrae,  and  insomnia.  Paralysis  of  the  third  nerve  is  common 
The  reflexes  are  at  first  increased  and  later  diminished  or  disappear.  Perverted 
appetite  is  frequently  observed,  and  may  lead  the  patient  to  gluttony  or  to  abhor- 
rence of  food.    In  the  late  stages  of  the  disease  all  of  thg  cerebro-soinal  symp- 


GRAIN  AND  VEGETABLE  '  335 

toms  are  increased.  Mild  cases  may  run  ten  or  fifteen  years,  but  the  average 
duration  is  about  five  years.  In  the  most  advanced  cases  mental  disturbance, 
in  the  form  of  depression,  acute  melancholy  or  insanity,  adds  a  stroke  that  makes 
the  picture  more  gruesome." — L,.  M.  Beeman. 

"The  spine  was  found  quite  rigid,  however,  especially  in  the  splanchnic 
area.  The  whole  of  the  spine  was  abnormally  rigid,  but  this  I  am  led  to 
believe  is  reflex,  rather  than  primary. 

"The  osteopathic  treatment  was  given  every  day  and  often  twice  per  day 
to  overcome  this  rigid  condition  and  to  keep  the  spinal  muscles  relaxed.  There 
certainly  is  no  specific  osteopathic  lesion  accounting  for  pellagra,  hence  there 
can  be  no  specific  treatment  given ;  but  on  the  same  principle  that  we  treat 
pneumonia,  measles,  scarlet  fever,  etc.,  successfully  without  recognizing  or 
removing  a  specific  lesion,  so  we  can  deal  with  pellagra.  That  character  of 
treatment  which  removes  the  cause  of  nerve  impingement,  or  circulatory  dis- 
turbance, and  promotes  elimination  of  disease  toxins,  is  the  treatment  indicated. 

"To  that  end  the  diet  should  be  regulated  and  adapted  to  each  individual 
case.  Corn  products  were  eliminated  from  the  food  of  my  patients,  otherwise 
a  light,  well-balanced  diet  was  given." — E.  W.  Patterson. 

"The  diet  I  am  using  on  all  cases  now  under  treatment.  Is  ten  ounces  of 
fresh  beef  per  day  and  plenty  of  fresh  vegetables,  except  cabbage,  collards, 
etc.,  two  ounces  of  sugar  in  egg  custard,  absolutely  no  corn  bread,  rice,  hominy, 
or  grits.  It  will  be  apparent  to  the  reader  that  the  purpose  of  this  diet  is  to 
eliminate  as  much  as  possible  the  articles  of  food  the  patient  eats  or  has  eaten 
as  a  sole  diet;  for  investigation  proves  beyond  doubt  that  all  pellagrins  eat 
practically  the  same  thing  365  days  in  the  year  and  that  is  largely  composed 
of  starchy  focrd.  I  allow  them  to  cook  their  vegetables  with  salt  pork,  but  do 
not  allow  them  to  eat  the  pork. 

"In  addition  to  the  dietetic  treatment,  of  course,  the  osteopathic^  lesions  are 
given  proper  attention  and  the  symptoms  are  cared  for  as  they  arise,  but  thd 
distressing  symptoms  almost  always  rapidly  subside  under  this  radical  change 
of  diet."— E.  C.  Armstrong,  D.O. 


GRAIN  AND  VEGETABLE  POISONING 

(Sitotoxismus) 

Ergotism.  The  prolonged  use  of  bread  made  from  rye  con- 
taminated with  claviceps  purpurea  (ergot  fungus)  causes  digestive 
disturbances  and  later  one  of  two  forms,  gangrenous  or  convulsive 
symptoms. 

The  gangrenous  form  begins  in  spasmodic  muscular  contrac- 
tions, pain,  paresthesias,  anesthesias,  and  finally  blood  stasis,  gan- 
grene resulting  usually  in  the  fingers  and  toes  although  sometimes 
in  the  nose  and  ears. 

The  convulsive  form  is  accompanied  by  a  prodromal  period  of 
one  to  two  weeks  of  headache,  slight  fever,  occasional  tingling  or 
pain.  This  is  succeeded  by  muscular  cramps  and  spasm  during 
which  there  is  painful  spasmodic  clenching  of  the  hands  and  hyper- 
extension  of  the  feet.  In  very  severe  cases,  there  is  early  delirium 
or  epilepsy  but  dementia  or  melancholia  are  more  frequent.  Ataxia 
may  be  present.  The  degeneration  of  the  posterior  spinal  columns 
resembles  that  of  tabes  dorsalis. 


3^  FOOD  POISONING 

Lathyrism  (Lupinosis)  is  due  to  eating  food  made  from  the 
seeds  of  the  vetches,  Lathyrus  sativa  or  L.  cicera,  and  produces 
symptoms  of  spastic  paraplegia,  most  frequently  affecting  the  legs 
only. 

Potato  Poisoning  is  due  to  the  solanin,  the  amount  of  which 
may  be  increased  over  the  normal  under  certain  circumstances  by 
the  action  of  the  bacillus  solaniferum  noncolorabile  and  the  ba- 
cillus solaniferum  colorabile,  occurring  in  those  potatoes  which  are 
partially  exposed  above  the  ground  or  in  those  sprouted  during 
storage. 

The  symptoms  are  chills,  fever,  headache,  vomiting,  diarrhea, 
colic,  and  great  prostration.  Jaundice  may  occur  and  collapse  is 
not  infrequent.    The  patients  recover. 

Mushroom  Poisoning  is  less  common  now  than  formerly,  yet 
incidents  occasionally  occur.  Fresh  morels  are  dangerous;  the 
poison  disappears  on  drying.  Nausea,  diarrhea,  vomiting,  hemo- 
globinemia  and  jaundice  may  precede  death ;  if  the  poison  taken 
was  small,  or  if  the  stomach  is  quickly  emptied,  recovery  may 
occur.  Red  agaric  (amanita  muscari)  is  very  dangerous;  con- 
vulsions, gastro-intestinal  symptoms,  slow  pulse,  dilated  pupils, 
salivation,  coma  and  death  follow  when  this  is  eaten,  unless 
speedy  removal  of  the  poison  is  secured. 


POISONING  FROM  NITROGENOUS  FOODS 

Milk  Poisoning  (Galactotoxismus)  is  marked  by  gastro-intes- 
tinal and  choleraic  symptoms  and  high  fever. 

In  Cheese  Poisoning  (Tyrotoxismus)  the  fever  is  not  continuous 
and  collapse  occurs  early. 

Mussels  (Mytilis  Edulis)  produce  mytilotoxin  if  they  have 
been  placed  in  filthy  water.  The  symptoms  are  of  an  acute  poison 
without  fever,  profound  nervous  symptoms  with  collapse  appear- 
ing rapidly.     There  are  no  gastro-intestinal  symptoms. 

Fish  Poisoning  (Ichthyotoxismus)  is  unattended  by  fever,  the 
symptoms  are  referable  to  the  nervous  system  and  collapse  occurs 
early. 

Meat  Poisoning  (Kreotoxismus)  is  due  either  to  the  alkaloidal 
products  of  decomposition  (true  ptomaine) ;  or  to  organisms, 
usually  bacillus  botulinus,  bacillus  enteritidis,  or  proteus  vul- 
garis and  allied  organisms.  These  gain  access  to  meat  after 
slaughter  and  produce  a  chemical  poison,  without  evidences  of 
decomposition,  or  they  may  be  swallowed  with  food  and  produce 
their  poison  within  the  body.  Sausage  poison  (botulinus;  allan- 
tiasis) is  destroyed  by  boiling. 


PROTEIDS  337. 

Diagnosis.  One  form  (true  ptomaine)  resembles  atropin  poi- 
soning, appears  within  a  very  short  time,  with  dryness  of  throat, 
hoarseness,  dysphagia,  rapid  pulse,  dilatation  of  the  pupils  (which 
do  not  respond  to  light),  nausea,  vomiting,  abdominal  pain, 
diarrhea,  and  prostration.  Death  is  not  infrequent  and  recovery 
is  slow. 

The  more  common  form  may  appear  at  once  or  after  an 
incubation  of  12  to  48  hours  during  which  there  may  or  may  not 
be  prodromal  symptoms  of  malaise,  anorexia,  nausea,  and  colicky 
pains. 

Chilliness  or  rigor  is  followed  by  fever,  101*  to  104°,  prostra- 
tion, giddiness,  faintness,  cold  perspiration,  great  thirst,  headache 
and  backache,  diarrhea,  crampy  tearing  and  burning  pain  in  the 
chest  or  between  the  shoulders,  and  increasing  abdominal  pain. 
The  clammy  perspiration  becomes  more  pronounced ;  the  pulse  is 
rapid,  100  to  128,  and  later  may  become  thready ;  there  is  extreme 
muscular  weakness ;  cramps  in  the  legs  and  arms  are  followed  by 
convulsive  movements;  there  are  paresthesias  of  various  forms. 
Choleraic  symptoms  are  present  in  some  cases.  In  mild  cases,  the 
symptoms  of  acute  gastro-intestinal  irritation  and  muscular  weak- 
ness with  fever  are  the  main  manifestations.  In  more  severe  cases, 
the  fever  is  replaced  by  collapse. 

Treatment.  In  all  these  forms  of  acute  poisoning,  the  offend- 
ing material  must  be  eliminated  speedily,  without  causing  inflam- 
mation of  the  gastro-intestinal  membranes.  The  stomach  tube 
and  the  enema  may  be  used  freely.  Strenuous  purgation  may  so 
inflame  the  membranes  as  to  facilitate  absorption  of  the  poison. 
After  the  alimentary  canal  seems  fairly  clean  a  diet  chiefly  cellu- 
lose should  be  given  for  several  days.  The  further  treatment  is 
that  of  acute  gastritis  and  acute  enteritis,     (q.  v.) 


PART   VII 
DISEASES  OF  THE  NERVOUS  SYSTEM 


CHAPTER  XXXIII 
DISEASES  OF  THE  MENINGES 

GENERAL  DISCUSSION 

Both  spinal  and  cerebral  meninges  are  subject  to  infection. 
Tumors  are  rare  and  are  usually  of  a  benign  nature.  The  bacterial 
invasion  may  be  through  direct  extension  around  the  roots  of  the 
cerebro-spinal  nerves  or  the  infectious  agent  may  be  carried  by 
the  blood;  occasionally  there  may  be  direct  invasion  of  the  men- 
inges from  the  rupture  of  an  abscess  or  from  injuries.  Mastoid 
abscesses  may  rupture  into  the  meninges.  The  direct  extension 
from  the  nasal  membrane  upward-  around  the  roots  of  the  olfactory 
nerves  is  certainly  responsible  for  some  meningeal  infections. 
Meningeal  tuberculosis  is  probably  the  result  of  blood-born  infec- 
tion as  is  the  case  with  syphilis. 

The  blood  vessels  of  the  meninges  are  controlled  by  the  vaso- 
motor nerves  from  sy;npathetic  ganglia;  these,  in  turn,  are  con- 
trolled from  the  lateral  horn  cells  of  the  spinal  cord,  and  homo- 
logous centers  in  the  medulla  and  the  midbrain.  The  spinal 
meninges  thus  may  have  their  circulation  disturbed  by  bony  lesions 
of  the  first  thoracic  to  the  third  lumbar  vertebrae,  and  the  cerebral 
meninges  may  be  affected  by  lesions  of  the  upper  thoracic  ver- 
tebrae or  by  axis,  atlas,  or  occiput  lesions. 

Gravity  is  a  factor  in  causing  meningeal'  congestion  when  the 
blood  vessels  have  deficient  tone,  as  may  be  the  case  in  the  pres- 
ence of  bony  lesions,  such  as  have  been  mentioned,  or  in  the  pres- 
ence of  exhausting  illness,  as  typhoid,  or  when  toxins  affect  the 
vascular  walls,  as  in  scurvy,  influenza,  and  certain  other  acute  or 
cachectic  diseases.  For  this  reason  the  supine  position  is  to  be 
avoided,  during  any  serious  or  long-continued  illness. 

The  pia  and  arachnoid  are  to  be  considered  as  one  membrane, 
in  disease ;  inflammation  of  these  usually  attacks  the  dura  to  some 
extent,  and  vice  versa.  Disease  of  the  dura  is  associated  with 
nerve-root  symptoms  more  often  and  more  intimately  than  is  dis- 
ease of  the  pia-arachnoid. 

Meningeal  diseases  have  usually  a  grave  prognosis,  and  satis- 
factory treatment  is  difficult.  Surgical  interference  is  usually 
dubious,  though  it  may  give  good  results  in  selected  cases.     By 

338 


PACHYMENINGITIS  339 

far  the  most  important  thing  is  the  prophylaxis  of  meningeal 
invasion ;  this  must  be  based  upon  the  consideration  of  the  etiolog- 
ical factors. 

Epidemic    cerebro-spinal    meningitis    is    discussed    with    other 
acute  infectious  diseases. 


PACHYMENINGITIS 

Inflammation  of  the  dura  mater  may  affect  chiefly  either  the 
extradural  space  (external  pachymeningitis),  or  the  subdural  space 
(internal  pachymeningitis).  Either  the  cerebral  or  the  spinal  dura 
may  be  involved. 

Cerebral  External  Pachymeningitis  is  due  to  trauma,  middle 
ear  disease,  syphilis,  or  disease  of  the  skull.  The  symptoms  are 
often  indefinite,  but  include  constant,  dull  headache  in  nearly  all 
cases.  Chills  and  fever,  drowsiness  and  stupor,  rarely  convulsions 
and  paralysis,  may  suggest  the  diagnosis.  Choked  disk  is  present, 
and  is  due  to  the  increased  intracranial  pressure.  Symptoms  of 
pyemia,  with  leucocytosis,  may  appear.  The  history  of  injury, 
previous  middle  ear  disease,  etc.,  may  help  in  the  diagnosis. 

Cerebral  Internal  Pachymeningitis  may  follow  the  external 
form,  or  may  not  be  associated  with  it.  It  is  found  in  alcoholics, 
epileptics,  the  insane,  and  paralytic  dements.  Rarely  it  may  appear 
in  childhood,  after  acute  infections.  The  condition  is  hemorrhagic ; 
successive  subdural  hemorrhages  occur,  and  these  become  organ- 
ized, so  that  at  autopsy  a  laminated  false  membrane  may  be  found ; 
this  may  or  may  not  be  stained  with  hemoglobin  and  its  derivatives. 
Headache,  convulsions,  paralysis  are  the  most  common  symptoms. 
Each  hemorrhage  may  be  associated  with  a  fairly  typical  epileptic 
attack ;  the  progress  of  events  may  be  much  slower  than  ordinary 
epileptic  fits  in  some  cases.  Cortical  epilepsy  is  frequent;  this 
may  lead  to  localizing  symptoms,  and  to  surgical  relief.  The 
paralysis  may  be  upon  the  same  side  as  the  hemorrhage ;  this  may 
be  due  to  the  pressure  of  the  opposite  side  against  the  skull ;  or 
to  flexion  of  the  brain  stem,  thus  causing  pressure  upon  the  pyra- 
midal tracts  of  the  opposite  side.  After  organization  of  the  clot, 
the  paralysis  is  upon  the  opposite  side  of  the  body,  as  is  to  be 
expected  from  the  anatomical  relations. 

Spinal  External  Pachymeningitis  results  from  trauma;  verte- 
bral disease,  either  syphilitic,  tubercular,  or  other;  from  the  pres- 
sure of  tumors,  etc. ;  it  is  always  secondary.  The  symptoms  are 
mostly  referable  to  involvement  of  the  nerve  roots. 

Spinal  Internal  Pachymeningitis  is  due  to  alcoholism,  syphilis, 
trauma,  or  extensions  from  vertebral  disease.  It  is  usually  hem- 
orrhagic, and  is  most  frequent  in  the  cervical  enlargement  (pachy- 


340  THE  MENINGES 

meningitis  cervicalis  hypertrophica).  First,  involvement  of  the 
sensory  nerves  causes  neuralgic  and  neuritic  symptoms  of  the  arms 
and  shoulder  girdle;  paresthesias,  pains,  formication,  and  various 
reflex  muscular  symptoms  appear.  Later,  paralysis  of  the  hands, 
arms  and  shoulders  appears ;  this  is  of  the  lower  neuron  type,  and 
atrophy  may  be  speedy.  Third,  the  legs  show  spastic  or  upper 
neuron  paralysis,  due  to  the  pressure  upon  the  descending  tracts. 
Death  is  from  exhaustion,  after  months  of  illness,  or  earlier,  from 
involvement  of  the  phrenic  centers. 

Diagnosis.  The  symptoms  may  make  the  diagnosis  evident. 
Spinal  puncture  and  the  examination  of  the  cerebro-spinal  fluid 
may  show  the  etiological  agent.  Traumatic  cases,  some-  tumors, 
especially  osteoma,  and  cases  with  increased  intracranial  pressure, 
may  be  recognized  by  the  X-ray,  especially  in  stereoscopic  views. 
Blood  examination  shows  leucocytosis  in  pyogenic  cases;  dimin- 
ished eosinophiles  in  tubercular,  and  sometimes  eosinophilia  plus 
lymphocytosis  in  syphilitic  cases.  Wasserman's,  Noguchi's  and 
other  biological  tests  for  syphilis  should  be  made. 

Treatment.  In  traumatic  cases,  the  removal  of  bits  of  bone  or 
of  thickened  dural  areas  may  give  relief.  Drainage  of  the  cerebro- 
spinal fluid,  several  times  repeated,  is  of  value  under  certain  con- 
ditions.    Tumors  may  sometimes  be  removed. 

Palliative  measures  may  give  much  relief.  Very  gentle  general 
spinal  treatment  gives  relief  which  may  last  for  a  week  or  more. 
Counter-irritation,  ice  bags,  mustard  plasters,  heat,  may  give  tem- 
porary relief. 

Hygienic  conditions  must  be  corrected.  Alcohol,  sexual  indul- 
gence, excessive  meat  diet,  stimulating  foods  and  drinks  of  all 
kinds,  must  be  forbidden  for  a  long  time,  even  though  symptoms 
abate  markedly. 

Prognosis.  Complete  recovery  is  not  to  be  expected,  except  in 
early  trauma,  where  the  pressure  can  be  removed  before  tissue 
degeneration  has  begun.  Partial  recovery  is  to  be  expected  when 
the  causative  factor  is  amenable  to  treatment.  Improvement  may 
be  hoped  for  with  palliative  measures.  Death  may  occur  at  almost 
any  time,  but  may  be  postponed  for  months  or  even  years. 

LEPTOMENINGITIS 

Inflammation  of  the  pia-arachnoid  occurs  as  the  result  of  an 
infection;  rarely  trauma  gives  entrance;  usually  the  infectious 
agent  is  borne  by  the  blood.  The  meningococci,  the  pneumo- 
cocci,  typhoid  bacilli,  tubercle  bacilli,  and  the  streptococci  and 
staphylococci  of  various  types  are  the  most  frequent.  The  disease 
may  follow  any  of  the  acute  infectious  diseases,  measles,  mumps, 
diphtheria,   influenza,   qr   any   others.     Tubercular   meningitis   is 


lEPTOMENINGITIS  341 

more  common  in  children.  The  inflammation  may  involve  the 
spinal  membranes  alone,  the  cerebral  alone,  or  both.  Of  the 
cerebral,  the  basal  area  is  more  frequently  involved,  probably 
partly  on  account  of  gravity,  and  partly  on  account  of  the  many 
nerve  roots  and  blood  vessels,  which  present  so  great  areas  of 
folding  membranes  to  the  action  of  the  invading  agents. 

Cerebral  Leptomeningitis  of  the  convexity  is  characterized  by 
headache,  fever,  stupor  and  delirium.  Constipation,  coated  tongue, 
nausea,  projectile  vomiting,  convulsions,  are  common  symptoms. 
Photophobia  is  constant;  hypersensitiveness. to  all  sensory  impres- 
sions amounts  to  severe  pain  upon  any  stimulation  whatever. 

Basilar  Cerebral  Leptomeningitis  Is  characterized  by  the  symp- 
toms associated  with  inflammation  of  the  convexity,  and  also  by 
ptosis,  pupillary  changes,  strabismus,  facial  spasm  or  paralysis, 
athetoid  movements  of  the  hands,  especially,  and  the  delirium  is 
sometimes  characterized  by  weeping,  laughter,  and  apparent  expres- 
sions of  rage  or  other  passion. 

Spinal  Leptomeningitis  is  characterized  by  marked  pain  in  the 
back,  with  rigidity,  opisthotonos  and  retraction  of  the  head. 
Reflexes  are  first  marked,  then  diminished  or  absent.  Varying 
sensory  disturbances  are  present,  according  to  the  early  irritating, 
later  paralyzing  effects  upon  the  sensory  nerve  trunks,  roots,  and 
ganglia.  The  spinal  cord  may  be  involved,  with  paralysis,  bed 
sores,  incontinence  of  urine  and  feces,  and  other  symptoms  of 
meningo-myelitis. 

Serous  Meningitis  (wet  brain;  meningitis  serosa)  may  be 
either  acute  or  chronic.  It  involves  the  cerebral  membrane  almost 
exclusively.  In  its  chronic  form  it  gives  symptoms  of  brain  tumor. 
In  this  type  there  is  excessive  formation  of  cerebrospinal  fluid. 
The  condition  is  due  to  chronic  alcoholism.  The  basilar  membrane 
is  usually  involved,  as  well  as  the  convexity,  and  the  symptoms 
referable  to  the  involvement  of  the  cranial  nerves  are  often  severe. 

Diagnosis.  The  history  of  an  acute  infectious  disease,  of 
chronic  alcoholism,  or  the  presence  of  the  signs  of  tuberculosis  or 
syphilis  elsewhere  in  the  body,  with  the  symptoms  as  given,  should 
suggest  the  diagnosis.  The  examination  of  the  cerebrospinal  fluid, 
obtained  by  means  of  lumbar  puncture,  should  establish  the  nature 
of  the  disease.  In  serous  meningitis  this  fluid  is  great  in  amount, 
'escapes  under  pressure,  and  is  clear.  In  infectious  cases  there  is 
usually  a  rather  small  amount  of  a  cloudy  or  flocculent  fluid,  which 
usually  contains  the  infectious  agent.  Sometimes  this  is  not  to  be 
found  either  on  slides  or  in  culture;  injection  into  animals  may 
give  the  diagnosis  when  other  methods  fail. 


342  THE  MENINGES 

The  blood  examination  shows  marked  leucocytosis  in  purulent 
cases;  diminished  eosinophiles  in  tubercular  cases,  and  sometimes 
indications  of  other  less  common  etiological  factors. 

Treatment.  The  treatment  of  all  types  of  leptomeningitis  fol- 
lows closely  after  that  given  for  acute  infectious  cerebrospinal 
meningitis,  (q.  v.)  The  prognosis  is  always  grave.  Recovery  may 
occur,  but  usually  with  more  or  less  permanent  injury. 

CHRONIC  LEPTOMENINGITIS 

This  may  follow  the  acute  form,  or  may  occur  as  a  slow  and 
chronic  form  from  the  beginning,  as  the  result  of  alcoholism,  syph- 
ilis, and  possibly  as  the  result  of  intense  overstrain  of  the  muscles 
of  the  back  with  exposure  to  extremes  of  heat  and  cold. 

The  symptoms  are  referable  to  involvement  of  the  nerve  roots, 
and  include  hyperesthesias,  paresthesias,  and  anesthesias,  affecting 
the  sensations  of  heat,  cold  and  pain,  or  of  touch  and  muscle  sense, 
variably  and  at  different  times.  Motor  symptoms  include  spasms 
and  weakness,  rarely  paralysis.  Herpes,  slight  and  varying  dis' 
turbances  of  bladder,  rectum,  and  genital  functions,  and  progres- 
sive loss  of  all  powers  until  death  from  exhaustion  or  intercurrent 
disease  are  included  in  the  ordinary  history  of  the  disease. 

Treatment  is  limited  to  the  correction  of  the  causative  factors, 
and  such  general  spinal  treatment  as  may  be  indicated  on  exam- 
ination. 


CHAPTER  XXXIV 
DISEASES  AFFECTING  BOTH  BRAIN  AND  CORD 

MULTIPLE  SCLEROSIS 

(Insular  sclerosis;  lacunar  sclejosis;  disseminated  sclerosis) 
Multiple  sclerosis  is  one  of  the  most  common  of  organic 
nervous  diseases.  It  is  characterized  by  the  formation  of  plaques 
of  neurogliar  overgrowth  in  many  widely  distant  areas  of  the  nerv- 
ous system,  and  clinically  by  tremors,  weakness,  speech  disturb- 
ances, emotional  instability  and  visual  disturbances,  which  appear 
and  disappear  suddenly  or  slowly,  and  which  constantly  progress 
to  more  serious  symptoms,  to  helplessness  and  death. 

Pathology.  The  plaques  are  usually  slightly  denser  than  the  normal 
nerve  tissue,  and  are  of  a  pearly  luster.  They  are  composed  of  neuroglia  cells, 
and  usually  surround  a  small  blood  vessel.  Through  them  the  naked  axons 
pass,  often  fairly  normal  except  for  the  loss  of  the  fatty  sheaths,  and  which 
seem  to  carry  nerve  impulses  in  a  fairly  normal  manner.  The  nerve  cells 
often  retain  their  normal  appearance,  in  the  midst  of  the  plaques.  The  patho- 
genesis is  not  known.  It  has  been  supposed  that  the  degenerated  fatty  sheaths 
give  the  stimulus  to  the  neuroglia  which  causes  the  overgrowth;  the  proximity 
of  the  vessels  leads  to  the  view  that  the  disease  is  altogether  circulatory  in 
origin ;  it  is  supposed  that  congenital  peculiarities  of  the  neuroglia  predispose 
to  overgrowth,  and  that  this  is  excited  by  toxic  substances  in  the  circulating 
blood. 

Etiology.  The  sexes  are  probably  about  equally  aflfected,  though 
statistics  disagree  considerably.  Rarely  cases  are  reported  before 
puberty ;  after  that  age  they  are  frequent  until  after  thirty  years ; 
after  that  age  they  are  again  very  rarely  found.  The  exanthemata, 
malaria,  sunstroke,  typhoid  are  all  mentioned  as  causes;  this 
incidence  is  little  if  any  greater  than  might  be  expected  from 
the  laws  of  coincidence.  Strains  of  various  kinds  are  rather  more 
frequent  as  possible  etiological  factors.  A  neuropathic  ancestry  is 
probably  one  factor.  Metallic  poisons,  lead,  mercury,  and  probably 
arsenic,  are  considered  as  causes.  A  history  of  fright,  or  some 
other  profound  emotional  storm,  is  sometimes  given  as  the  cause 
of  the  disease;  in  such  cases  further  investigation  usually  eluci- 
dates earlier  symptoms ;  the  emotional  storm  is  usually  one  of  the 
first  recognizable  symptoms,  rather  than  a  real  cause  of  the  disease. 

Pseudosclerosis.  Certain  cases  diagnosed  as  multiple  sclerosis 
have  come  to  autopsy,  and  no  signs  of  sclerosis  have  been  found; 
doubtless  in  some  of  these  cases  the  patches  were  so  small  as  to 
be  overlooked.  On  the  other  hand,  the  possibility  of  functional 
imitation  of  the  disease  must  not  be  forgotten. 

343 


344  BRAIN  AND  CORD 

Familial  Sclerosis  (aplasia  axialis  extra-corticocollis)  is  a  very 
rare  form  of  multiple  sclerosis  which  appears  rather  constantly  in 
certain  families.    It  is  sometimes  directly  hereditary. 

Diagnosis.  This  rests  chiefly  upon  the  symptoms  and  history. 
The  onset,  in  early  adult  life,  is  insidious.  Usually  the  first  symp- 
tom is  a  weakness  in  one  leg;  soon  the  other  is  affected,  then  the 
arms,  and  other  muscles.  Complete  paralysis  is  rare,  in  the  early 
stages,  and  the  weakness  may  pass  away  for  days  or  weeks  at  a 
time.  Nystagmus  appears  early;  it  may  not  be  noticeable  except 
upon  voluntary  movements  of  the  eye-balls.  Retrobulbar  optic  nerve 
atrophy  may  be  the  first  symptom.  The  retina  often  shows  mar- 
ginal pallor  before  the  symptoms  of  the  disease  appear  elsewhere. 
After  a  few  weeks  the  intention  tremor  becomes  marked;  the 
speech  becomes  slow  and  drawling,  and  later  scanning.  Writing 
becomes  difficult,  on  account  of  the  tremor.  Vertigo  is  common, 
rarely  projectile  or  ordinary  vomiting.  Paresthesias  are  rather 
rare.  Bladder  symptoms  are  frequent  and  variable.  Rectal  and 
sexual  functions  are  usually  normal  until  late  in  the  disease. 

Mentality  usually  suffers.  Emotional  instability  is  constant; 
forced  laughing  and  weeping  are  frequent.  Less  commonly  demen- 
tia or  mania  is  present. 

The  location  and  nature  of  the  symptoms  depend  upon  the 
location  of  the  plaques.  Sometimes  involvement  of  the  lateral 
funiculi  gives  an  imitation  of  lateral  sclerosis;  in  other  cases 
implication  of  the  posterior  funiculi  causes  symptoms  of  tabes 
dorsalis.  Occasionally  the  diagnosis  is  impossible.  (Formes 
frustes.) 

The  disease  resembles  hysteria  in  many  ways,  and  certain  other 
organic  nervous  diseases  may  give  difficulty  in  diagnosis. 

Treatment.  This  can  be  only  palliative.  Rest,  good  hygiene, 
and  such  corrective  work  as  may  be  indicated  upon  examination 
are  helpful. 

It  must  be  remembered  that  these  patients  have  prospect  of 
remissions,  followed  by  exacerbations,  and  that  they  are  apt  to 
live  many  years,  unless  some  accident  or  intercurrent  disease  inter- 
feres. Hysteria  certainly  is  often  associated  with  sclerosis,  and 
functional  disorders  are  also  frequent;  treatment  for  the  relief 
of  symptoms  may  give  gratifying,  though  probably  temporary, 
results.  Patients  must  be  taught  to  make  the  best  of  their  lives, 
and  to  understand  that  while  serious  symptoms  may  occur  at  any 
time,  yet  that  these  are  not  to  be  thought  of  as  permanent;  it  is 
much  better  that  they  understand  these  things,  rather  than  that 
they  are  taught  not  to  expect  further  accidents.  They  should 
engage  in  such  pursuits  as  are  possible,  and  should  live  as  happily 
and  usefully  as  possible.  Interest  and  good  cheer  go  far  toward  pro- 


TABES  DORSALIS  345 

moting  general  health,  and  toward  preventing  the  functional  dis- 
orders so  often  associated  with  the  organic  disease. 

Especially  when  the  prognosis  is  not  frankly  given,  these 
patients  go  from  one  doctor  to  another,  and  from  one  patent  medi- 
cine to  another.  Being  erratic,  in  the  very  nature  of  things,  they 
try  everything  that  promises  relief,  without  much  judgment. 
"Nerve  tonics"  and  purgatives  seem  especially  attractive  to  them, 
and  are,  of  course,  either  inert  or  harmful. 

Prognosis.  Recovery  is  not  to  be  expected.  Improvement  is 
probable,  and  may  last  for  months.  Later  symptoms  may  appear 
at  any  time.  Life  is  probably  not  shortened  by  the  disease ;  rarely 
it  may  involve  cardiac  or  respiratory  centers.  Death  usually 
occurs  from  some  intercurrent  affection,  or  some  accident. 

TABES  DORSALIS 

(Locomotor  ataxia;  posterior  leucomyelitis) 

This  is  a  parasyphilitic  disease,  characterized  by  symptoms 
indicative  of  the  degenerations  of  sensory  neuron  systems.  These 
include  lancinating  pains  in  the  legs,  loss  of  the  knee-jerk,  Argyll- 
Robertson  pupil,  analgesia  of  the  lateral  surfaces  of  the  legs  with 
tactile  hyperesthesia  of  the  trunk,  and  other  variable  symptoms. 
The  girdle  sensation,  visceral  crises  and  ataxia  due  to  the  sensory 
disturbances  are  usually  present.  Lymphocytosis  of  the  cerebro-. 
spinal  fluid  and  increase  of  its  globulins  are  significant;  Wasser- 
man  and  Noguchi  are  usually  positive.  The  disease  is  charac- 
terized anatomically  by  degeneration  of  the  fasciculus  gracilis  (the 
tract  of  Goll)  and  sometimes  of  the  fasciculus  cuneatus  (tract  of 
Burdach). 

Etiology.  Syphilis  is  the  most  important  cause  of  the  disease. 
Exposure  to  violent  climatic  changes,  especially  standing  in  cold 
water,  heavy  lifting,  or  violent  exertion,  and  injury  to  the  lumbar 
spinal  column  are  sometimes  concerned  in  the  etiology.  Atypical 
cases  in  which  the  eye  symptoms  are  always  absent  and  the  gastro- 
intestinal symptoms  are  usually  wanting  sometimes  occur  as  the 
result  of  the  factors  just  mentioned  in  the  absence  of  syphilitic 
history. 

Pathology.  The  constant  pathological  findings  include  the  atrophy  of  the 
long  sensory  nerve  fibers  in  the  posterior  funiculi  of  the  cord.  The  posterior 
nerve  roots  and  the  cells  of  the  sensory  ganglia  become  atrophied  later  in  the 
course  of  the  disease.  A  diffuse  pachymeningitis  of  the  cerebral  concavity  is 
usually  present  and  this  may  be  responsible  for  the  ocular  symptoms.  Other 
syphilitic  evidences  are  usually  present  in  typical  cases  of  locomotor  ataxia.  The 
brain  and  the  cardio-vascular  system  are  usually  affected. 

Diagnosis.  The  symptoms  are  very  typical,  though  there  is 
much  variation  in  the  time  of  their  onset.  Sometimes  the  diges- 
tive, sometimes  the  ocular,  sometimes  the  sensory,  and  sometimes 


346  BRAIN  AND  CORD 

the  motor  symptoms  may  first  appear.  In  the  typical  case  the  gait 
is  first  affected.  The  patient  finds  himself  stumbling  more  fre- 
quently than  usual,  especially  in  the  dark.  He  is  unable  to  walk 
as  well  as  usual,  and  it  is  noticed  that  the  toes  turn  outward  and 
that  the  foot  drops  when  the  forward  step  is  taken ;  the  legs  are 
swung  out  in  a  semicircle  in  order  to  prevent  the  toes  from  scraping 
the  ground.  The  ataxia  becomes  gradually  more  marked  until 
the  patient  is  unable  to  walk  at  all.  The  arms  are  rarely  affected. 
The  typical  gait  is  almost  pathognomonic.  The  lightning  pains 
usually  appear  about  the  time  of  the  ataxia.  These  are  excru- 
ciatingly severe  and  come  and  go  with  lightning  rapidity.  It  is 
very  difficult  to  relieve  this  suffering;  even  moderate  doses  of 
morphine  are  often  ineffective.  The  girdle  sensation  is  a  sense  of 
constriction  which  may  appear  first  around  the  legs,  but  which 
usually  is  noted  first  around  the  abdomen.  The  sensation  follows 
the  disturbance  of  the  spinal  nerves  and  in  typical  cases  the  girdle 
rises  with  the  progressive  degeneration  of  the  sensory  neurons. 
The  gastric  crises  usually  resemble  severe  attacks  of  acute  gas- 
tritis. They  may  not  be  associated  with  any  dietetic  indiscretion, 
but  sometimes  appear  to  be  precipitated  by  irregular  meals,  by 
alcohol  or  by  emotional  storms.  Diarrhea  with  intestinal  colic 
is  sometimes  present.  More  rarely  the  place  of  the  gastric  crisis 
is  taken  by  crises  involving  the  larynx,  heart,  vessels,  or  other 
viscera.  The  Argyll-Robertson  pupil  is  present.  This  means  that 
the  pupils  react  normally  to  distance,  but  do  not  change  in  size 
with  changes  in  the  light.  Pupils  constantly  dilated,  constantly 
contracted,  or  of  an  oval  or  comma  shaped  outline  are  sometimes 
found.  Vision  is  not  disturbed,  except  as  the  result  of  retinal  hem- 
orrhages or  optic  nerve  atrophy,  or  some  other  ocular  lesion ;  these 
usually  occur.     Diplopia  may  be  an  early  symptom. 

Impotence  and  incontinence  may  occur  early  or  late. 

The  tendon  reflexes  are  first  exaggerated,  usually  for  only  a 
very  short  time,  then  diminish  and  finally  disappear.  The  loss  of 
the  sensations  of  heat,  cold  and  pain  during  the  later  stages  is 
associated  with  diminished  nutrition  of  tissues  affected.  Charcot's 
joint  usually  affects  the  knee.  This  is  a  rarefying  osteitis  and 
arthritis.  The  knee  may  reach  a  size  almost  or  quite  equal  to  the 
waist  of  the  patient.  It  is  not  usually  painful  but  adds  greatly 
to  the  difficulty  of  walking.  A  lax  condition  of  the  joints  of  the 
legs,  especially  of  the  hips,  is  present.  It  is  not  rare  for  a  patient 
Ito  be  able  to  wrap  his  legs  around  his  neck  in  much  the  same 
way  that  a  normal  individual  could  twist  his  arms  around  his  neck. 
Injury  to  the  feet  is  unnoticed,  and  burrowing  abscesses  may  result 
from  infections.  The  bones  of  the  foot  may  be  destroyed  in  this 
way  with  no  pam  to  the  patient.  Romberg's  sign  consists  in  the 
patient's  inability  to  stand  alone  with  the  eyes  closed.  It  is  present 
in  other  ataxias  as  well  as  in  this.     No  characteristic  blood  or 


PARALYTIC  DBMBNTIA  347 

urinary  changes  have  been  reported.  The  examination  of  the 
cerebrospinal  fluid  shows  lymphocytosis.  A  positive  reaction  is 
given  to  the  Wasserman  test  or  any  of  the  later  modifications  of 
this. 

H.  F.  Goetz  shows  by  spinograms  a  posterior  lumbar  spine  in  typical  loco- 
motor ataxia.  Spinograms  of  syphilitics  without  locomotor  ataxia  do  not  show 
this  spinal  conformation.  Hence,  if  all  cases  of  locomotor  ataxia  have  this 
posterior  displacement  of  the  lumbar  vertebrae,  then  all  cases  of  syphilis  must  be 
examined  with  the  object  in  view  of  discovering  whether  they  have  posterior 
displacement  of  the  lumbar  vertebrae,  and  if  so,  this  lumbar  displacement  must 
be  corrected  with  the  second  object  in  view  of  preventing  locomotor  ataxia. 

"The  impottance  of  this  point  is  also  apparent  if  the  diagnosis  of  locomotor 
ataxia  is  made  early,  for  then  by  correcting  this  displacement  or  disalignment 
of  the  lumbar  vertebrae,  we  may  not  only  prevent  further  advancement  of  the 
condition  but  also  by  reestablishing  the  normal  blood  supply  and  nutrition, 
cure  those  cases  in  which  no  great  havoc  has  been  wrought.    In  other  words: 

"Removing  this  posterior  disalignment  of  the  lumbar  vertebrae  should  act  as 
a  preventive  or  prophylaxis  in  locomotor  ataxia." — H.  F.  Goetz. 

Treatment.  In  very  early  cases,  increased  mobility  of  the 
dorso-lumbar  spinal  column,  rest  of  the  affected  part  and  a  hygienic 
manner  of  living  usually  result  in  stopping  the  course  of  the  dis- 
ease, and  frequently  in  partial  restoration  of  the  loss  of  function. 
The  bones  are  fragile;  careless  treating  may  result  in  fracture  of 
the  ribs  or  the  bones  of  the  legs  or  arms. 

The  older  medical  treatment  with  mercury  and  the  iodides 
has  been  largely  superseded  by  the  present  methods  which  are 
based  upon  the  use  of  certain  delicate  arsenic  compounds.  If  these 
are  to  be  employed  in  any  case  they  should  be  given  by  doctors 
who  have  made  a  special  study  of  their  administration. 

The  educational  treatment  is  extremely  important.  The  patient 
should  be  taught  to  perform  first  very  simple  movements  and  then 
gradually  more  complex  movements  until  in  many  cases  walking 
again  becomes  possible.  This  fact  seems  to  be  produced  through 
the  education  of  nerve  centers  or  nerve  paths  not  ordinarily  func- 
tional under  normal  conditions  and  not  injured  by  the  syphilitic 
poison. 

The  prognosis  for  complete  recovery  is  very  serious.  The  prog- 
nosis for  considerable  improvement  under  the  osteopathic  treat- 
ment without  drugs  is  very  good.  In  untreated  cases  the  disease 
may  stop  at  any  time  and  the  condition  of  the  patient  remain 
stationary  for  many  years.  When  no  intermissions  in  the  progress 
of  the  disease  occur,  death  is  to  be  expected  within  five  to  ten 
years  after  the  occurrence  of  the  first  symptoms. 

GENERAL  PARALYTIC  DEMENTIA 

(General  paresis;  general  paralysis  of  the  insane) 
This  is  a  parasyphilitic  disorder  occurring  in  late  middle  life 
and  characterized  by  successive  attacks  of  paralysis  associated  with 
progressive  dementia. 


348  BRAIN  AND  CORD 

Etiology.  It  is  probably  always  due  to  syphilis  plus  alcohol. 
Sexual  excesses  are  also  accessory  etiological  factors.  The  dis- 
ease usually  begins  in  the  second  or  third  decade  after  the  occur- 
rence of  the  primary  lesion.  Overwork,  overworry,  nervous  strain 
and  other  mental  injuries  are  frequently  considered  by  the  patient 
and  his  friends  to  be  responsible  for  the  disease.  Investigation 
shows,  however,  that  the  actual  importance  of  these  factors  is  con- 
siderably overestimated. 

Pathology.  The  pathological  changes  in  the  brain  are  very  conspicu- 
ous. Thickenings,  hemorrhages,  and  adhesions  are  found  in  the  meninges  and  the 
cranium.  In  the  brain  itself  are  the  evidences  of  syphilitic  vascular  disease  asso- 
ciated with  small  foci  of  softening  and  neurogliar  proliferation.  Microscopic 
examination  shows  the  cerebellar  neurons  undergoing  various  forms  of  degen- 
eration and  atrophy.  Old  and  fresh  hemorrhagic  areas  are  scattered  through 
the  brain  substance.    Yellow  pigment  is  abundant  in  the  large  nerve  cells. 

Diagnosis.  The  symptoms  are  very  characteristic.  At  first  the 
patient  shows  signs  of  what  is  ordinarily  called  a  nervous  break- 
down. A  superficial  examination  at  this  time  gives  a  diagnosis  of 
neurasthenia.  Sometimes  this  period  of  nervous  depression  is  pre- 
ceded and  sometimes  it  is  followed  by  a  period  of  marked  exalta- 
tion. During  the  time  of  exaltation  the  patient  is  full  of  big  plans 
for  the  future ;  he  borrows  money  to  extend  his  business ;  he  buys 
many  things  on  the  installment  plan;  he  begins  work  whose  com- 
pletion might  require  several  lifetimes;  he  invents  impossible 
machines ;  he  -sleeps  little  and  considers  himself  fortunate  in  being 
able  to  devote  more  than  the  ordinary  time  to  the  pursuance  of 
his  new-found  ambitions.  He  may  suflFer  from  exaltation  in  the 
sexual  sphere;  if  he  is  a  widower  or  bachelor,  he  is  likely  to  marry 
a  young  girl,  or  he  may  cause  grief  to  his  family  by  his  infatua- 
tions for  young  women.  It  is  unfortunate  that  during  this  stage  of 
exaltation  the  true  nature  of  the  condition  is  so  rarely  recognized, 
for  it  often  happens  that  men  introduce  such  absurd  business  enter- 
prises that  they  jeopardize  the  futures  of  children  and  wife. 

During  the  .stage  of  nervous  depression,  melancholia  may  be 
marked.  The  character  becomes  suspicious,  irritable  and  careless; 
the  patient  may  show  apparently  more  than  normal  ingenuity  in 
devising  methods  of  circumventing  the  members  of  his  family; 
emotional  irritability  becomes  more  and  more  marked ;  he  laughs 
and  cries  easily  upon  slight  or  no  provocation ;  convulsive  attacks 
resembling  epilepsy  are  likely  to  occur ;  slight  cerebral  hemorrhages 
precipitate  paralysis,  which  is  more  likely  to  affect  the  right  side 
of  the  body,  and  which  usually  involves  the  speech  centers;  one 
attack  of  paralysis  follows  another  until  finally  the  whole  body  is 
involved.  The  dementia  is  progressive;  the  patient  gradually 
losing  interest  in  himself,  or  his  surroundings,  and  finally  becoming 
mindless  and  completely  paralyzed.  He  may  live  in  this  pitiable 
condition  for  a  number  of  months  until  paralysis  involving  the 
cardiac  or  respiratory  centers  brings  a  welcome  death. 


DISSEMINATED  MYELITIS  349 

In  the  early  stages,  that  is,  during  the  period  of  exaltation  or 
the  period  of  nervous  depression,  diagnosis  may  be  doubtful..  It 
should  be  a  matter  of  ordinary  routine  to  make  a  Wassermann  or 
other  biological  test  for  syphilis  in  every  case  in  which  apparently 
causeless  neurasthenia  occurs  in  men  in  middle  life.  Pupillary 
changes  are  usually  present.  The  Argyll-Robertson  pupil,  the 
oval  pupil,  or  inequality  in  the  two  pupils,  are  all  important  factors 
in  an  early  diagnosis.  The  absence  of  these  findings  has  no  sig- 
nificance, but  when  they  are  present  syphilitic  history  should  be 
strongly  suspected. 

Treatment.  Since  the  symptoms  of  the  disease  are  due  to 
actual  nervous  degeneration  and  since  serious  structural  perver- 
sions precede  any  symptoms,  it  is  evident  that  treatment  is  com- 
monly of  very  little  value  after  the  diagnosis  is  possible. 

Prophylaxis  is  important.  The  prevention  of  syphilis  is  the 
prevention  of  paretic  dementia.  Men  who  have  had  syphilis  may 
avoid  this  form  of  insanity  by  living  continent  and  temperate  lives. 

The  prognosis  is  hopeless  unless  an  early  diagnosis  is  made. 
The  course  of  the  disease  is  sometimes  halted  for  some  months  or 
years,  but  its  further  progress  to  death  is  inevitable. 


TABO-PARALYSIS 

There  are  certain  cases  of  parasyphilitic  disease  in  which  the  spinal  de- 
generation resembles  that  of  locomotor  ataxia,  and  the  cerebral  degeneration 
resembles  that  of  paretic  dementia.  To  these  cases  the  term  "tabo-paralysis" 
has  been  applied.  The  mental  derangement  is  less  pronounced  than  in  the 
ordinary  case  of  paralytic  dementia;  the  pupillary  changes  are  early  and 
marked ;  the  ataxia  is  variably  marked  but  never  absent ;  the  occurrence 
of  epileptoid  attacks  is  rather  rare.  Speech  is  less  frequently  an 
early  symptom,  and  the  paralysis  is  oftener  a  weakness  with  incoordination 
than  a  true  paralysis.  The  disease  is  probably  to  be  considered  an  intermediate 
type  between  locomotor  ataxia  and  paretic  dementia,  rather  than  a  combination 
of  the  two  diseases.  The  treatment  and  pathology  are  practically  the  same  as 
in  paretic  dementia.  The  prognosis  is  somewhat  different;  the  progress  oi 
tabo-paralysis  is  more  constant,  and  less  subject  to  remissions,  than  is  either 
paretic  dementia*  or  locomotor  ataxia. 


DISSEMINATED  MYELITIS     • 

In  this  form  there  are  many  patchy  areas  of  inflammation  "in 
the  cord,  medulla,  and  brain.  The  disease  is  due  to  almost  any  of 
the  ordinary  infectious  agents,  and  may  follow  any  fever.  The 
symptoms  are  those  of  acute  myelitis,  plus  the  symptoms  of  bulbar 
and  brain  involvement.  The  ocular  disturbances  include  variations 
in  the  size  of  the  pupils,  various  incoordinations  of  the  extrinsic 
eye  muscles,  and  visual  disturbances.  Mentality  may  be  variously 
affected  according  to  the  area  involved.    Coma  and  delirium  may 


350  BRAIN  AND  CORD 

precede  death.  The  bulbar  symptoms  may  be  immediately  fol- 
lowed by  death,  or  may  be  limited  to  the  centers  of  the  cranial 
nerves;  twitchings  and  paralysis  of  the  face,  paresthesias  of  sight, 
taste,  smell  and  hearing  may  occur. 

Treatment  is  almost  useless,  and  death  is  apt  to  occur  at  any 
time  within  a  week  or  so  after  diagnosis  becomes  possible. 

BONY  LESIONS  AS  LOCALIZING  FACTORS 

In  diseases  affecting  both  braih  and  cord,  it  is  very  evident  that  some 
localizing  factors  are  present.  Different  patients  present  different  symptoms, 
according  to  the  location  of  the  lesions  in  each  case,  but  what  factors  deter- 
mine the  location  of  the  lesions  in  any  case  is  not  yet  to  be  determined  exactly. 

Vasomotor  nerves  have  been  demonstrated  for  the  brain  and  for  the  men- 
inges of  both  brain  and  cord.  Vasomotor  nerves  for  the  cord  itself  have  not 
yet  been  certainly  demonstrated  but  their  existence  seems  fairly  certain.  Bony 
lesions  are  certainly  not  less  efficient  in  modifying  spinal  and  cerebral  circula- 
tion than  in  modifying  renal  and  pulmonary  circulation.  Thus,  lesions  affecting 
any  segment  of  the  spinal  cord  must  be  considered  efficient  in  localizing  gen- 
eral disease  in  that,  and  neighboring,  segments.  Lesions  of  the  occiput  and  the 
cervical  vertebrae  are  efficient  in  modifying  the  cerebral  circulation,  and  thus  in 
localizing  the  effects  of  disease  in  the  brain.  The  localization  of  vasomotor 
control  within  the  brain  has  not  yet  been  completed. 

The  functional  activities  of  nerve  centers  depend  chiefly  upon  the  nerve 
impulses  reaching  them.  Bony  lesions  which  limit  the  mobility  of  any  joint 
lessen  the  normal  stimulation  to  the  related  centers.  Bony  lesions  which  are 
irritating  send  abnormal  impulses  into  the  related  centers,  and  thus  these  have 
undue  stimulation.  When  a  lesion  associated  with  limited  mobility  is  asso- 
ciated with  increased  mobihty  above  and  below  the  affected  joint,  or  when  it  is 
associated  with  marked  hypersensitiveness,  the  disturbance  of  the  function  of 
the  related  nerve  centers  may  be  profound. 

All  these  factors,  disturbed  circulation  through  the  nerve  centers,  lessened 
stimulation,  and  irritation,  are  concerned  in  lessening  the  resistance  of  the 
nerve  centers  to  infection  and  to  the  influence  of  poisons,  and  thus  are  local- 
izing factors  in  diseases  affecting  the  central  nervous  system  -in  a  somewhat 
general  manner. 


CHAPTER  XXXV 
DISEASES  OF  THE  SPINAL  CORD 

GENERAL  DISCUSSION 

The  diseases  which  affect  the  spinal  cord  itself  are  character- 
ized by  various  motor,  sensory  and  trophic  disturbances  varying 
as  the  injury  destroys  the  anterior  or  posterior  gray  matter,  the 
white  matter  or  the  nerve  roots  or  the  spinal  ganglia. 

Pathology.  Spinal  cord  diseases  are  characterized  by  pathological 
findings  which  vary  from  those  practically  negligible  in  the  functional  disease 
to  absolute  destruction  of  the  cord  or  of  some  area  in  it  as  in  syringo-myelia 
or  myelomalacia. 

In  the  gray  matter  the  nerve  cells  may  show  merely  a  slow  progressive" 
diminution  in  size  which  goes  on  to  complete  destruction  as  in  chronic  anterior 
poliomyelitis  or  they  may  show  various  degenerated  types  with  chromatolysis, 
extrusion  of  nuclei,  vacuolization  and  swelling  of  nucleus  and  protoplasm,  fatty 
degeneration,  pigmentation  and  other  less  easily  recognized  changes.  The 
neuroglia  may  be  unaffected;  may  increase  in  amount  either  by  multiplication 
of  the  nuclei  with  cellular  division  or  without  (this  leading  to  a  syncytium-like 
appearance),  or  the  fibers  may  increase,  forming  a  dense  felt-like  tissue  in  the 
injured  spinal  matter.  The  blood  vessels  may  be  uninjured  or  they  may  show 
the  effects  of  ischemia,  hyperemia,  congestion,  or  inflammation  in  varjang 
degrees.  In  the  spinal  diseases  due  to  syphilis  changes  in  the  walls  of  the 
blood  vessels  are  usually  to  be  found.  In  myelitis  vascular  changes  are  probably 
an  important  factor  in  the  determination  of  the  characteristics  of  the  disease. 
The  walls  of  the  blood  vessels  may  show  arterio-sclerotic  changes;  the  intima 
may  show  thickening  which  may  go  on  to  the  point  of  total  occlusion.  When 
this  process  occurs  inside  the  spinal  cord  itself  the  death  and  degeneration  of  the 
infarct  area  are  inevitable  since  there  are  no  anastomoses  within  the  cord.  In 
the  meninges  similar  conditions  are  usually  associated  with  chronic  pachymen- 
ingitis of  varying  degrees.  The  wealth  of  anastomotic  relations  in  the  meninges 
maintains  a  fairly  good  arterial  supply  even  when  rather  large  vessels  are 
occluded. 

Etiology.  The  causes  of  disease  of  the  spinal  cord  are 
extremely  varied  and  numerous.  Of  aril  these,  however,  the  infec- 
tions hold  first  place  and  of  all  the  infections  syphilis  either 
directly  or  indirectly  is  a  factor  of  paramount  importance.  Acute 
anterior  poliomyelitis  or  infantile  paralysis  is  the  next  most  impor- 
tant of  the  spinal  diseases  due  to  specific  infection.  The  organisms 
responsible  for  many  of  the  ordinary  infectious  diseases,  such  as 
typhoid  fever,  jDneumonia,  scarlet  fever,  measles,  as  well  as  those 
found  in  pyemia  may  gain  entrance  into  the  spinal  cord  itself  and 
there  set  up  extremely  rapid  and  usually  fatal  spinal  inflammations. 
Inflammatory  processes  in  the  meninges  may  extend  into  the 
spinal  cord  and  this  condition  also  is  usually  very  rapid  and  fatal. 

Toxic  influences  of  all  kinds  may  be  considered  in  connection 
with  diseases  of  the  spinal  cord.     Alcoholism  goes  with  syphilis 

351 


352  THU  SPINAL  CORD 

as  an  etiological  factor  in  spinal  diseases;  as  indeed  these  belong 
together  in  most  discussions  of  personal  and  social  pathology. 
Lead,  mercury,  and  other  inorganic  salts  sometimes  exert  serious 
influence  upon  the  spinal  cord.  The  diminished  use  of  calomel  as 
a  drug  is  removing  one  cause  of  spinal  disease.  The  poisons, 
whatever  they  may  be,  that  are  responsible  for  pernicious  anemia, 
insular  sclerosis  and  a  few  other  diseases  of  doubtful  etiology 
bring  about  the  disease  of  islands  of  the  nerve  tissue  with  symp- 
toms localized  according  to  the  area  affected.  Spinal  diseases  due 
to  this  factor  are  usually  easily  recognized  by  the  history. 
Whether  concussions,  jars  or  blows  can  be  considered  important 
in  the  cause  of  the  spinal  disease  in  any  given  case  is  not  always 
easily  determined.  Certainly  the  occurrence  of  injuries  to  the 
spinal  column  does  seem  to  localize  and  often  to  predispose  to 
spinal  disease  when  other  conditions  are  favorable  to  the  develop- 
ment of  a  pathological  condition. 

The  place  of  the  bony  lesion  as  an  etiological  factor  in  spinal 
cord  disease  has  not  yet  been  positively  determined..  There  is 
very  good  reason  for  believing  that  bony  lesions  exert  a  detri- 
mental influence  upon  the  circulation  in  the  meninges  and  at  least 
indirectly  upon  the  circulation  in  the  segments  of  the  cord. 
Though  the  presence  of  vasomotor  nerves  within  the  spinal  cord 
itself  has  not  been  demonstrated,  the  fact  remains  that  spinal 
diseases  appear  to  aflfect  first  those  areas  of  the  spinal  cord  which 
send  sensory  nerve  fibers  to  subluxated  vertebrae  and  ribs.  It 
must  not  be  forgotten  in  this  connection  that  resistance  to  infec- 
tion generally,  elimination  of  poisons,  and  the  nutrition  of  the 
body  are  all  subject  to  profound  variations  as  the  result  of  slight 
malpositions  of  the  bone's  and  ligaments  and  the  abnormal  mus- 
cular tension  so  often  associated  with  these. 

Perhaps  there  is  no  one  factor  much  more  responsible  for 
spinal  diseases  than  inheritance.  Except  for  infantile  paralysis, 
most  of  the  spinal  diseases  in  children  are  due  to  inheritance.  This 
inheritance  follows  Mendel's  law  so  that  such  diseases  are  more 
frequently  referred  to  as  familial  than  hereditary.  Many  of  the 
diseases  whose  chief  cause  is  infectious  or  toxic  have  bad  inher- 
itance as  a  predisposing  factor.  In  many  of  the  diseases  asso- 
ciated with  syphilis,  alcoholism,  sexual  excesses  and  so  on,  it  is 
difficult  to  determine  the  relative  proportion  of  blame  due  to  these 
things  in  themselves,  to  the  inheritance  of  nervous  weakness  or  to 
the  fact  that  the  different  members  of  the  same  family  are  usually 
educated  to  the  same  habits  and  the  same  use  of  life. 

Diagnosis.  Some  general  factors  in  diagnosis  may  be  given 
here.  Lesions  of  the  anterior  gray  matter  alone  bring  atrophy  and 
paralysis  of  the  skeletal  muscles  innervated  from  the  area  affected. 
In  such  a  case  there  are  no  sensory  disturbances  except  that  the 


GENERAI.  DISCUSSION  353 

weakened  muscles  may  sometimes  ache  or  feel  sore.  Such 
muscles  undergo  atrophy  with  varying  degrees  of  rapidity.  There 
is  present  a  reaction  of  degeneration  and  loss  of  reflexes;  there 
is  loss  of  muscular  tone  so  that  in  early  stages  the  muscle  is 
very  flaccid  and  soft.  Later  the  overgrowth  of  connective  tissue 
usually  associated  with  the  atrophy  of  the  muscles,  makes  them 
hard  and  dense  and  tlie  contraction  of  these  connective  tissues 
together  with  the  unbalanced  action  of  antagonists  leads  to  various 
deformities. 

Disease  of  the  posterior  gray  matter  is  usually  associated  with 
more  or  less  destruction  of  the  anterior  gray  matter.  In  such  dis- 
eases sensory  disturbances  are  likely  to  be  very  profound.  Pares- 
thesias include  the  sense  of  formication,  tinglings,  pain,  sensations 
of  heat  and  cold  and  the  girdle  or  stocking  or  glove  sensations. 
Total  loss  of  sensation  in  some  area  is  usually  present.  Anes- 
thesias, analgesias,  lack  of  temperature  sense  or  of  the  sense  of 
muscular  effort  may  appear  in  varying  degrees  according  as  the 
injury  is  or  is  not  strictly  localized  in  the  gray  matter.  It  must  be 
remembered  that  the  sensations  of  heat,  cold  and  pain  are  carried 
chiefly  by  way  of  the  nerve  cells  in  the  posterior  gray  matter, 
while  the  sensations  of  muscular  effort  and  touch  are  carried 
chiefly  by  the  long  white  tracts  in  the  posterior  funiculi.  To  a 
certain  extent,  however,  it  is  probable  that  each  of  these,  pathways 
includes  at  least  some  of  all  the  sensations  named  so  that  any 
destruction  of  the  gray  matter  of  the  cord  is  associated  with  dim- 
inution of  all  somatic  and  visceral  sensations. 

Diseases  of  the  white  matter  of  the  cord  are  mostly  limited 
to  those  of  the  long  tracts  so  far  as  our  present  methods  of  diag- 
nosis are  concerned.  The  most  important  of  these  on  the  sensory 
side  is  locomotor  ataxia  in  which  the  long  fibers  of  the  fasciculus 
gracilis  and  to  a  less  extent  those  of  the  fasciculus  cuneatus  are 
involved.  On  the  motor  side  destruction  of  the  lateral  and  the 
anterior  descending  cerebrospinal  or  pyramidal  tracts  leads  to  the 
symptoms  of  lateral  sclerosis. 

In  those  diseases  in  which  heredity  or  a  congenital  condition 
is  responsible  for  the  disease  the  blood  cells  usually  show  the 
presence  of  many  immature  and  atavistic  types.  In  the  infectious 
diseases  the  blood  shows  the  same  characteristics  that  are  present 
in  the  same  or  similar  infections  occurring  in  other  parts  of  the 
body.  In  many  cases  of  spinal  disease  of  doubtful  diagnosis  the 
blood  examination  will  make  this  real  condition  clear. 

It  often  happens  that  cases  ^f  pernicious  anemia  show  their 
first  symptoms  as  paralysis  or  atrophy  referable  to  the  spinal 
cord  lesion.  Under  such  conditions  the  blood  examination  may 
throw  much  light  upon  the  condition  and  it  should  be  made  in 
every  case  in  which  there  is  the  least  doubt  of  the  diagnosis.  The 
blood  pressure  is  usually  very  high  in  senile  and  syphilitic  diseases. 


354  THE  SPINAL  CORD 

The  urine  often  shows  no  changes  whatever.  When  there  is 
any  marked  destruction  of  nerve  matter  phosphorus  may  be 
increased  beyond  the  amount  expected  from  the  patient's  diet. 
In  making  this  test  it  is  best  to  put  the  patient  upon  an  almost 
phosphorus-free  diet,  for  a  few  days  before  the  24-hour  sample 
of  urine  is  collected.  A  good  test  ior  this  is  to  have  the  patient 
begin  his  phosphorus-free  diet  with  a  few  charcoal  tablets.""  Then 
when  the  black  color  due  to  the  charcoal  has  ceased  to  appear  in 
the  feces,  collection  of  the  urine  may  be  begun.  In  diseases  with 
marked  degeneration  of  the  nerve  tissue  or  with  abscess  formation 
an  excess  of  indican  is  present.  In  diseases  associated  with  trophic 
symptoms  the  kidneys  may  be  seriously  involved  either  directly 
or  as  the  result  of  the  harm  due  to  the  elimination  of  the  products 
of  the  abnormal  metabolism  elsewhere  in  the  body.  When  the 
bladder  is  involved  the  urine  may  show  the  effects  of  this  condi- 
tion. When  catheterization  is  necessary,  the  bladder  is  very  likely 
to  become  infected  and  the  urine  then  shows  the  results  of  the 
cystitis  so  produced. 

At  present  the  X-ray  is  limited  to  the  recognition  of  the  dis- 
eases of  the  vertebrae  as  these  may  affect  the  spinal  cord.  Tumors 
and  bone  diseases  may  be  recognized  by  the  X-ray  and  since  such 
conditions  cause  symptoms  which  are  atypical,  the  X-ray  should 
be  used  in  all  cases  of  doubtful  diagnosis. 

Treatment.  In  many  cases  of  disease  of  the  spinal  cord  there  is 
very  little  efficient  treatment.  Nearly  everything  in  the  way  of 
drugs  has  received  at  least  one  voice  of  commendation  as  to  its 
use  in  spinal  cord  diseases  and  several  times  as  many  voices  of 
condemnation  for  its  use  in  these  same  diseases.  The  di'agnosis 
usually  gives  the  indications  for  treatment.  During  the  acute  stage 
of  any  of  the  infections  the  treatment  must  include  suitable  meas- 
ures for  reducing  the  fever,  such  as  are  used  in  fevers  in  general. 
The  patient  should  not  be  permitted  to  lie  upon  his  back  but  must 
be  kept  upon  the  side  or  in  the  left  lateral  or  the  right  lateral 
position.  The  prone  position  is  good,  except  for  the  difficulty  of 
getting  the  head  in  a  comfortable  place.  In  most  cases  an 
extremely  gentle  relaxation  of  the  spinal  muscles  is  usually  very 
grateful  to  the  patient  and  should  be  repeated  from  one  to  several 
times  each  day.  Ice  packs  are  sometimes  of  value.  Massage  of 
the  arms  and  legs  is  sometimes  good.  Usually  no  foods  except 
fruit  juices  are  given  during  the  acute  stage.  In  the  chronic  dis- 
eases the  treatment  varies  according  to  the  condition.  Contrac- 
tures of  the  limbs  and  deformities  of  various  kinds  are  best 
treated  by  suitable  orthopedic  surgery.  Massage  of  the  affected 
muscles  and  very  mild  faradization  are  sometimes  helpful  in  the 
treatment  of  the  muscles  paralyzed.  In  diseases  associated  with 
incoordination  of  the  muscles  but  no  true  paralj'sis  or  where  the 


HEMORRHAGE  '  355 

paralysis  is  of  the  upper  neuron  type  exercises  looking  toward  re- 
education are  of  considerable  value.  This  is  especially  true  of  the 
diseases  of  the  long  sensory  tracts  such  as  locomotor  ataxia. 

In  both  acute  and  chronic  conditions  the  osteopathic  measures 
to  be  employed  depends  entirely  upon  the  indications  as  these  are 
interpreted  by  the  experience  and  good  judgment  of  the  prac- 
titioner. 

The  sensory  disturbances  are  very  hard  to  deal  with.  Generally 
ice  packs  give  more  relief  than  do  applications  of  heat.  Alterna- 
tions of  heat  and  cold  may  give  relief  when  neither  alone  is  effi- 
cient. Usually  in  the  girdle  sensation  massage  is  grateful. 
Sometimes  a  rather  tight  bandage  placed  over  the  girdle, 
relieves  the  discomfort.  The  same  thing  is  true  of  painting  the 
skin  with  celloidin.  Great  care  must  be  employed  to  prevent  the 
skin  from  being  injured  in  any  of  these  measures.  The  danger  of 
bed  sores  and  of  serious  infection  from  slight  abrasions  of  the  skin 
must  be  kept  in  mind.  Careful  nursing  is  the  best  thing  in  these 
conditions.  An  important  factor  in  dealing  with  the  disturbed  sen- 
sations is  the  education  of  the  patient.  He  must  find  interest  in 
life  and  must  thus  be  made  to  forget  as  far  as  possible  the  things 
that  are  so  annoying  and  uncomfortable.  The  occurrence  of  these 
diseases  which  are  so  often  hopeless  so  far  as  recovery  is  concerned 
is  in  itself  a  dreadful  thing  and  the  patient  must  be  encouraged  to 
find  such  occupations  and  interests  as  to  get  the  most  good  out  of 
such  a  life  as  will  be  possible  to  him. 

The  prognosis  varies  according  to  the  area  and  amount  of  the 
spinal  tissue  destroyed  and  to  a  less  extent  upon  the  possibility 
of  securing  compensatory  development  of  other  nerve  centers  and 
tracts.  The  amount  of  cooperation  which  the  patient  is  willing  to 
give  is  sometimes  very  important.  Under  suitable  cases  nerve 
surgery  gives  a  good  prognosis.  The  prevention  of  the  spinal 
cord  diseases  lies  in  the  prevention  of  the  causes.  Stringent  isola- 
tion of  infantile  paralysis  and  other  contagious  diseases  is  impor- 
tant. Perhaps  the  greatest  thing  of  all  is  the  prevention  of  alco- 
holism and  syphilis.  Those  diseases  of  the  spinal  cord  which  come 
on  during  middle  age  or  later  should  be  lessened  with  the  dimin- 
ished use  of  alcohol  and  drugs.  A  large  preventive  field  lies  in 
keeping  the  structure  thoroughly  adjusted. 


HEMORRHAGE  OF  THE  SPINAL  CORD 

(Meningeal  apoplexy;  hematorrachis ;  hematomyelia ;  spinal  apoplexy) 
Hemorrhage  into  the  spinal  membranes  occurs  from  rupture 
of  an  aneurysm  into  the  extrameningeal  space,  or  from  erosion  of 
an  artery  by  malignant  neoplasms,  caries  of  vertebrae,  or  as  the 
result  of  hemorrhagic  diseases,  hemophilia,  scurvy,  and  others. 


356  *  THE  SPINAL  CORD 

Hemorrhage  into  the  cord  itself  is  usually  due  to  trauma,  or 
to  rupture  of  small  vessels  which  have  become  atheromatous  or 
otherwise  diseased ;  it  may  occur  in  the  hemorrhagic  diseases. 

In  either  case,  the  symptoms  depend  upon  the  extent  and  the 
area  of  the  hemorrhage.  The  onset  may  be  extremely  sudden 
(apoplectic),  with  paralysis  and  various  sensory  disturbances;  or 
the  injury  may  be  so  slight  as  to  make  diagnosis  impossible.  The 
extradural  and  the  subdural  spaces  may  contain  a  large  amount  of 
blood  without  any  particular  difficulty  or  pressure.  The  symp- 
toms, if  any,  are  due  to  pressure  upon  the  nerve  roots.  Hem- 
orrhage into  the  subpial  space  or  the  substance  of  the  cord  produce 
serious  symptoms,  usually  immediate  and  serious,  unless  the 
amount  of  hemorrhage  is  extremely  minute. 

Death  usually  results  within  a  few  hours;  if  this  does  not 
occur,  the  later  symptoms,  the  treatment  and  the  prognosis  are 
those  of  myelitis. 

MYELITIS 

This  term  is  applied  to  any  inflammatory  disease  of  the  spinal 
cord.     Several  types  of  the  disease  are  recognized. 

Meningomyelitis  is  an  inflammation  involving  both  meninges 
and  spinal  nervous  matter;  it  is  generally  considered  syphilitic. 

Poliomyelitis  is  an  inflammation  of  the  gray  matter,  and  may 
be  either  anterior,  as  in  infantile  paralysis,  or  posterior,  as  in  cer- 
tain forms  of  acute  myelitis. 

Leucomyelitis  aflfects  the  white  matter;  it  may  be  posterior, 
as  in  tabes  dorsalis,  lateral,  as  in  amyotrophic  muscular  atrophy,  or 
may  affect  any  area,  as  in  pernicious  anemia. 

,  Transverse  Myelitis  involves  almost  or  quite  the  entire  cord, 
for  one  or  several  segments. 

Disseminated  Myelitis  is  characterized  by  its  widespread 
patches  of  inflammatory  foci. 

Myelomalacia  is  probably  due  to  occlusion  of  an  end  artery ;  the 
area  affected  undergoes  softening,  resolution,  and,  later,  absorp- 
tion. Neurogliar  growth  fills  the  area  with  scar-like  tissue,  if  life 
persists  after  the  acute  process  is  complete. 

Pathology.  The  nerve  cells  of  the  affected  area  show  chromatolysis, 
vacuolization,  swelling  of  the  protoplasm;  the  nuclei  are  eccentric  or  extruded, 
vacuolated,  and  present  variations  in  staining.  The  neuroglia  cells  may  be  degen- 
erated, or  may  show  signs  of  rapid  multiplication ;  the  walls  of  the  blood 
vessels  may  be  almost  or  quite  normal,  or  they  may  show  inflammatory  changes 
— a  proliferative  endarteritis  is  especially  frequent,  and  this  is  an  important 
cause  of  the  softening  found  in  myelomalacia. 

The  axons  are  swollen  and  bubble-like ;  granular  degeneration  is  everywhere 
found. 

Etiology.  The  causes  of  the  different  forms  are  slightly 
variable ;  the  treatment  and  prognosis  must  also  be  considered  for 
each  form. 


MYELITIS  '  357 

ACUTE  INFECTIOUS  MYELITIS 

This  is  an  acute  infectious  disease  of  the  spinal  cord,  charac- 
terized by  symptoms  referable  to  the  nature  of  the  infectious 
agent  and  to  the  area  of  the  nerve  tissue  destroyed. 

Etiology.  Any  of  the  ordinary  infectious  diseases  may  affect 
the  cord,  though  rarely  does  this  occur.  It  may  be  difficult  to 
isolate  the  infectious  agent  from  the  lesions,  though  injection  into 
animals  usually  gives  positive  results.  The  infection  may  be 
carried  by  the  blood  or  the  lymph  vessels,  or  may  affect  the  cord 
through  extension,  especially  in  Pott's  disease.  Whitlow,  car- 
buncle, parturition,  may  initiate  the  disease. 

Diagnosis.  This  rests  partly  upon  the  symptoms;  partly  upon 
the  history  of  the  presence  of  some  infectious  disease.  In  tuber- 
cular cases  the  onset  may  be  somewhat  gradual,  with  progressive 
sensory  and  motor  symptoms,  leading,  usually,  to  death  within  a 
week  or  two.  In  cases  due  to  the  ordinary  acute  infections,  the 
onset  is  rather  sudden,  with  increased  pyrexia,  vomiting  and  nausea 
— rarely  projectile  vomiting — and  very  severe  burning  pain  in  the 
back.  Within  a  few  hours  flaccid  paralysis  in  the  muscles  inner- 
vated from  the  segments  of  the  cord  affected,  with  variable  sensory 
symptoms,  makes  its  appearance.  Usually  the  legs  and  lumbar 
centers  are  first  affected ;  bladder  and  rectal  symptoms  are  serious 
from  the  beginning,  and  the  disease  progresses  rapidly  upward 
until  involvement  of  the  respiratory  muscles  terminates  life.  When 
the  disease  affects  other  segments  of  the  cord,  the  location  of  the 
symptoms  vary ;  the  visceromotor  involvement  is  almost  constant. 
When  the  upper  thoracic  cord  is  affected,  flaccid  paralysis  of  both 
arms  with  spastic  paralysis  of  both  legs  may  occur.  Paralysis  of 
the  intercostal  muscles  compels  diaphragmatic  breathing;  when  the 
cardiac  centers,  or  the  phrenic  center  is  involved,  death  is  imme- 
diate. 

Treatment.  This  is  commonly  of  little  value,  after  the  diagnosis 
becomes  possible.  The  patient  should  be  given  no  food,  but  plenty 
of  water.  The  position  should  be  left  lateral  or  prone,  so  that  the 
influence  of  gravity  may  lessen  the  spinal  congestion ;  also,  less 
heat  is  permitted  in  the  spinal  region,  and  the  back  is  accessible 
to  treatment.  The  spinal  muscles  may  be  very  gently  examined, 
.and  any  deep  contractions  relieved.  Unless  the  correction  of 
vertebral  lesions  is  very  easily  secured,  it  is  better  not  to  attempt 
this  until  after  the  acute  symptoms  have  subsided.  Ice  bags  may 
be  placed  over  the  spinal  column;  gentle  sponging  with  mod- 
erately cool  water  is  better  in  most  cases.  The  position  of  the 
patient  must  be  changed,  after  the  first  few  hours,  rather  fre- 
quently, as  bed  sores  are  almost  inevitable.  A  water-bed  or  air-bed 
should  be  secured  if  possible. 


358  ^  THE  SPINAL  CORD 

Prophylaxis.  During  the  progress  of  the  disease,  bladder  infec- 
tion should  be  carefully  avoided ;  catheterization  is  often  necessary, 
and  the  greatest  of  care  is  necessary  to  avoid  infection ;  the  resist- 
ance of  the  tissues  is  greatly  lowered,  and  infection  is  much  more 
dangerous  and  less  easily  avoided  than  under  ordinary  conditions. 

The  disease  itself  is  avoided  by  care  during  the  progress  of  the 
acute  infectious  diseases,  tuberculosis,  and  other  rarer  infections — 
as  actinomycosis — and  by  maintaining  at  all  times  as  good  a 
circulation  of  as  good  blood  as  is  possible.  Sick  persons  ought 
never  be  left  to  lie  upon  the  back,  but  should  be  turned  from  time 
to  time;  blood  vessels,  weakened  from  fever,  may  yield  to  effects 
of  gravity,  when  the  relief  given  by  the  change  of  position  may 
prevent  injury. 

CHRONIC  MYELITIS 

True  chronic  myelitis  is  probably  rather  rare.  Erb's  syph- 
ilitic paraplegia  is  probably  the  same  disease.  According  to  Erb's 
account  the  disease  is  characterized  by  five  qualities.  First,  it  is  of 
syphilitic  origin.  Second,  the  reflexes  are  greatly  exaggerated 
without  being  associated  with  any  marked  muscular  rigidity. 
Third,  bladder  trouble  of  insidious  onset  and  with  symptoms  of 
varying  intensity  usually  antedate  the  paralysis.  Fourth,  pares- 
thesias are  present  and  usually  associated  with  the  paralyzed  areas. 
Fifth,  the  disease  has  always  very  gradual  development  and  it 
may  improve  under  the  antisyphilitic  remedies.  The  diagnosis 
and  pathology  are  such  as  would  be  indicated  by  the  above  defini- 
tion of  the  disease. 

Cases  of  chronic  myelitis  are  reported  as  following  the  acute 
form ;  probably  these  are  either  cases  of  mistaken  diagnosis,  or 
are  complicated  with  other  spinal  cord  lesions. 


COMPRESSION  OF  THE  SPINAL  CORD 

(Compression  myelitis) 

Etiology.  This  condition  is  due  to  trauma;  to  neoplasms;  or 
to  inflammatory  disease  of  vertebrae,  as  tuberculosis  or  syphilis. 
It  is  almost  always  associated  with  meningeal  inflammations  and 
with  myelitis. 

Diagnosis.  This  depends  upon  recognition  of  the  causative 
factors,  plus  the  symptoms  observed.  These  are  due  to  the  area 
affected. 

The  first  injury  is  usually  to  the  nerve  roots.  Pressure  upon 
the  posterior  roots  gives  pain,  neuralgic  in  character,  and  radiating 
along  the  various  nerves  of  that  area.  Paresthesias,  formication, 
pains,  are  followed  by  anesthesia.  Dissociation  of  sensations  may 
be  noted.   Pressure  upon  the  anterior  roots  causes  spasmodic  mu»- 


MENING0MYEUTI3  359 

cular  movements,  followed  by  paralysis  of  the  lower  neuron  type. 
Pressure  upon  the  white  substance  produces  variable  effects;  and 
this  is  closely  followed,  or  sometimes  preceded,  by  pressure  symp- 
toms referable  to  the  gray  matter  of  the  cord. 

The  X-ray  is  of  value ;  tumors  of  several  kinds,  caries,  and 
traumatic  causes  of  the  compression  are  thus  quickly  and  certainly 
recognized.  Stereoscopic  views  give  most  accurate  information  in 
all  but  the  simplest  cases. 

Treatment.  This  is  mostly  surgical  or  orthopedic.  If  the 
pressure  cannot  be  removed,  or  after  the  removal  of  the  pressure, 
the  treatment,  is  that  of  acute  myelitis. 

The  prognosis  depends  upon  the  possibility  of  removing  the 
cause  of  pressure  before  degeneration  of  the  nervous  tissue  has 
proceeded  to  any  great  extent,  and  the  power  of  recovery  left  in 
the  injured  tissues. 

MENINGOMYELITIS 

This  is  a  parasyphilitic  disease,  and  is  probably  never  found 
in  its  typical  form  except  as  the  result  of  gummy  inflammation 
of  the  meninges,  with  simultaneous  or  immediate  involvement  of' 
the  nerve  roots  and  the  cord  substance. 

Pathology.  The  spinal  membranes  are  thickened,  and  the  subdural 
and  subarachnoid  spaces  are  more  or  less  completely  filled  with  gummy  deposit. 
The  meninges  around  the  nerve  roots  are  involved  in  the  process,  and  present 
a  swollen  and  "stubby"  appearance.  From  the  pia,  wedge-like  projections  of  the 
gummy  and  proliferative  process  enter  and  penetrate  the  white,  then  the  gray 
matter,  destroying  the  tissues  in  turn. 

Etiology.  In  addition  to  the  syphilitic  infection,  overstrain  of 
the  spinal  muscles,  sexual  excesses,  and  exposure  to  extremes  of 
heat  and  cold  are  given  as  causes. 

Diagnosis.  The  onset  is  gradual,  with  pains  resembling  neu- 
ritis. Backache  is  usually  severe,  especially  in  the  lumbar  region. 
Motor  symptoms  of  a  neurotic  nature  follow;  then  disturbance  of 
reflexes,  incoordination,  and  the  disturbances  in  the  bladder,  rectum 
and  sexual  organs.  Impotence  and  priapism  are  not  unusual. 
Weakness  of  the  muscles  is  followed  by  paralysis,  of  the  lower 
neuron  type  in  the  area  of  the  affected  segments,  and  of  the  upper 
neuron  type  in  the  muscles  innervated  from  segments  below  the 
affected  area.  When  the  disease  is  limited  to  one  side  of  the  cord, 
as  it  may  be  for  a  short  time,  a  Brown-Sequard  paralysis  may  be 
present. 

When  symptoms,  first  of  nerve  trunk  involvement,  then  of 
\^hite  and  gray  spinal  involvement  appear,  with  history  or  evi- 
dences of  syphilis,  the  diagnosis  is  evident. 

Treatment.  The  treatment  for  syphilis  must  be  given,  (q.  v.) 
The  patient  must  avoid  overexertion,  alcohol,  sex  indulgence,  and 


360  THE  SPINAL  CORD 

any  excitement.  His  life  must  be  absolutely  hygienic;  his  food 
nonstimulating  and  abstemious.  Such  treatment  as  facilitates  the 
better  drainage  from  the  central  nervous  system  is  indicated. 


SYRINGOMYELIA 

This  is  a  disease  of  the  spinal  cord  and  medulla,  characterized 
by  neurogliar  overgrowth  and  cavity-formation,  with  symptoms 
referable  to  the  areas  destroyed. 

Pathology.  The  pathogenesis  is  unknown;  it  seems  to  depend  upon 
congenital  defect  in  the  neural  canal,  and  the  relation  between  nerve  cells  and 
glia  cells.  The  disease  is  most  common  in  the  cervical  enlargement,  next  in 
the  lumbar  enlargement,  and  occasionally  involves  other  parts  of  the  cord,  the 
entire  length  of  the  cord,  or  the  medulla.  It  affects  the  central  canal,  in  some 
part  of  its  extent,  almost  invariably,  and  is  thought  to  originate  in  the  ependyma 
cells.  It  involves  the  posterior  horns,  preferably,  and  destroys  the  lateral, 
anterior,  and  white  matter  less  frequently,  or  later.  Hemorrhagic  areas  are 
constant;  some  cases  appear  to  originate  in  an  old  hemorrhage  into  the  cord. 

Etiology.  This  is  very  uncertain.  The  disease  appears  about 
equally  in  the  sexes;  is  most  frequent  before  thirty,  and  the  first 
symptoms  are  often  observed  soon  after  puberty.  Investigation 
often  brings  out  earlier  symptoms.  Syphilis  is  not  directly  a 
cause ;  this  infection  may  lower  the  resistance  of  the  blood  vessels. 
History  of  trauma  is  not  common ;  the  slow  and  gradual  onset 
would  in  any  case  tend  to  obscure  slight  injuries. 

Diagnosis.  This  disease  may  be  suspected  when  the  sensations 
of  heat,  cold  and  pain  are  lost,  or  noticeably  diminished,  for  any 
part  of  the  body,  with  little  or  no  loss  of. tactile  and  muscle  sense. 
The  diagnosis  is  made  upon  the  symptoms  and  course  of  the  dis- 
ease; no  laboratory  findings  are  of  value. 

The  onset  is  remarkably  slow  and  gradual.  Slight  variations  in 
the  skin  sensations,  located  according  to  the  area  of  the  cord  first 
involved,  first  appear.  The  loss  of  the  temperature  sense  is  early, 
and  severe  burns  may  be  produced  without  pain.  The  nutrition 
of  the  skin  in  the  aflfected  area  becomes  disordered ;  slight  wounds 
do  not  heal  well;  the  skin  thickens,  and  skin  lesions  follow  which 
may  resemble  almost  any  of  those  mentioned  in  a  book  on  derma- 
tology. Leprosy  and  skin  tuberculosis  may  give  difficulty  in  the 
diagnosis.  Bed  sores  are  produced  with  remarkable  facility.  Vaso- 
motor disturbances  are  common ;  blebs  and  gangrene  may  suggest 
Raynaud's  disease.  Localized  areas  of  hyperidrosis  and  anhidrosis 
may  occur.  The  bones  break  very  easily ;  apparently  spontaneously 
sometimes. 

Sensory  disturbances  vary.  The  injury  of  the  posterior  horns 
and  the  gray  decussation  destroys  the  conduction  paths  for  heat, 
cold,  and  pain;  these  are  usually  lost;  tactile  and  muscle  sense  are 
often  diminished,  and  are  lost  if  the  posterior  white  tracts  are 


SYRINGOMYELIA  361 

involved.  Coordination  is  usually  diminished.  Various  pares- 
thesias- and  hyperesthesias  may  precede  the  sensory  loss. 

Motor  disturbances  are  variable,  also,  according  to  the  amount 
of  injury  to  the  anterior  horns,  the  lateral  descending  tracts,  and 
the  effects  produced  by  sensory  and  trophic  disturbances.  Paral- 
ysis is  of  the  lower  neuron  type,  at  the  level  of  the  cavity  and 
gliosis;  and  of  the  upper  neuron  type  below  the  lesion — from 
involvement  of  the  pyramidal  fibers.  Lower  neuron  paralysis  of 
the  arm,  with  upper  neuron  paralysis  of  the  leg,  is  not  rare. 
Variable  electrical  reactions  and  reflex  disturbances  depend  upon 
the  tissue  destroyed.  Muscular  tremor,  spasm,  and  twitchings  of 
muscle  groups  may  be  variably  present.  Symptoms  of  myotonia 
may  occur. 

Peculiar  overgrowth  of  one  or  both  hands,  or  one  or  both  feet 
may  result,  probably  from  the  trophic  effect  of  the  lesion ;  possibly 
from  the  underlying  causative  factor  of  the  gliosis.  The  affected 
parts  become  broad,  with  thick  skin  and  considerable  distortion 
of  parts.  The  paralysis  is  usually  marked,  and  the  deformity  may 
be  very  considerable. 

Morvans*  disease  is  a  form  of  syringomyelia  described  by 
Morvan;  it  is  characterized  by  progressive  wasting  and  paralysis 
of  the  upper  limbs,  sensory  loss,  and  painless  whitlows  which 
result  in  more  or  less  loss  of  tissues — the  fingers  may  drop  off, 
joint  by  joint,  with  little  or  no  sensation.  Neuritis  may  be  present 
at  an  early  stage. 

Treatment.  Since  the  disease  has  a  basis  of  congenital  defect, 
it  is  evident  that  recovery  is  not  to  be  expected.  Some  relief  of 
the  symptoms  may  follow  careful  treatment.  First,  it  is  necessary 
to  provide  good  circulation  of  good  blood,  with  elimination  of  the 
waste  products  of  metabolism  as  rapidly  as  possible.  The  cor- 
rection of  structural  conditions  must  be  accomplished  with  great 
care,  remembering  the  delicacy  of  the  bones  of  these  patients,  as 
well  as  the  fact  that  very  slight  pressure  often  produces  evil 
effects.  For  the  prevention  of  bed  sores,  a  water-bed,  air-bed,  or 
specially  constructed  mattress  may  be  employed.  Let  the  patient 
lie  in  the  left  lateral  position,  or  otherwise  prevent  the  gravity  flow 
of  the  blood  from  adding  to  the  spinal  congestion.  As  long  as  it 
is  possible,  he  may  remain  out  of  bed;  but  overexertion  must  be 
prevented. 

The  sensory  disturbances  may  be  relieved  by  hot  and  cold 
applications  and  by  very  gentle  massage.  The  loss  of  the  heat, 
cold  and  pain  sensations  permit  serious  injury  from  hot  water 
bottles,  touching  hot  things,  permitting  the  feet  to  become  too 
cold;  neglecting  accidental  injuries  especially  to  the  feet,  with 
later  infection  of  the  injured  tissues,  and  many  other  factors. 


362  THE  SPINAL  CORD 

Coordination  can  be  preserved,  to  some  extent,  by  reeducation 
of  the  affected  muscle  groups ;  exercises  should  be  specially  devised 
for  each  patient,  with  reference  to  his  especial  needs. 

The  various  orthopedic  appliances  useful  in  infantile  paralysis 
may  be  used  with  help,  after  the  paralysis  has  become  fixed. 

Occasionally  symptoms  of  syringomyelia  are  produced  by  dural 
tumors;  these  are  operable  in  certain  cases,  and  a  symptomatic 
recovery  may  be  hoped  for.  When  the  pain  is  very  severe,  and 
the  hopelessness  of  the  disease  is  certainly  recognized,  partial  or 
complete  section  of  the  spinal  cord  above  the  cavity  may  give 
relief;  after  such  an  operation  the  trophic  disturbances  are  usually 
relieved,  doubtless  on  account  of  the  relief  of  the  pain  and  the 
consequent  better  rest  and  better  nutrition. 

Prognosis  is  always  very  gloomy  for  recovery.  Life  may  not 
be  shortened  by  the  disease.  Palliative  results  are  all  that  can  be 
expected  from  the  best  of  treatment. 


CAISSON  DISEASE 

(Diver's  paralysis;  the  bends) 

This  is  a  paralytic  disease  resulting  from  sudden  change  from 
high  to  low  atmospheric  pressure,  and  characterized  by  cramps, 
pain,  and  varying  paralysis  which  is  more  or  less  permanent. 

Pathogenesis.  Under  the  high  air  pressure  necessary  for  work  in 
caissons  or  within  the  suits  of  divers  under  deep  sea  pressures,  the  blood  takes 
up  more  air  than  it  can  hold  in  solution  under  normal  pressures ;  also,  the  blood 
is  driven  from  the  surface  of  the  body  into  the  deeper  organs.  When  the 
pressure  is  too  speedily  diminished,  the  vessels  are  unable  to  accommodate 
themselves  to  the  sudden  change,  and  stasis  and  hemorrhages  result ;  also,  the 
air  is  set  free  from  the  blood  in  the  capillaries  with  almost  explosive  force. 
In  the  soft  tissues,  this  produces  pain  and  cramps  of  the  muscles,  but  no  perma- 
nent injury.  In  the  spinal  cord,  however,  and  to  a  somewhat  less  extent  within 
the  skull,  the  force,  of-  this  escaping  air  seriously  injures  the  delicate  tissues. 
The  injury  is  rather  greater  in  the  cord,  because  the  small  canal  receives  sud- 
denly the  pressure  changes,  while  the  rigid  wall  prevents  escape  of  the  pressure. 
Within  the  skull,  the  openings  are  smaller,  proportionately,  and  decompression 
is  necessarily  somewhat  delayed.  The  greater  size  of  the  skull  also  permits 
greater  elasticity  of  the  contents,  and  the  escaping  air  produces  less  frequently 
serious  effects  than  in  the  spinal  cord. 

Etiology.  Men  who  are  alcoholic,  or  who  are  overfat,  or  are  at 
all  subject  to  arteriosclerosis,  are  most  easily  and  seriously  injured. 
Young  and  vigorous  men,  who  remain  under  pressure  not  more 
than  two  to  three  hours,  are  decompressed  slowly,  and  who  live 
hygienic  lives,  seem  able  to  engage  in  this  work  without  serious 
results.  The  greater  the  pressure,  the  shorter  the  time  that  is 
safely  endured.  Strenuous  working,  heavy  lifting,  haste,  also 
increase  the  danger.  At  three  atmospheres,  one  hour  should  be  the 
limit  of  time  at  work,  with  two  or  three  hours  intervening  rest,  at 


LANDRY'S  PARALYSIS  363 

normal  pressure.     Half  an  hour  to  an  hour  should  be  spent  in 
decompression,  according  to  pressure. 

Neuralgic  pains  in  the  muscles  and  joints,  with  giddiness,  are 
the  mild  symptoms.  •  Headache  and  tinnitus,  with  cramping  pains 
in  the  muscles;  then  anesthesia,  and  weakness  of  the  legs,  then  of 
the  entire  body,  are  noticed.  After  being  a  few  hours  or  a  day 
under  ordinary  pressure,  paralysis  develops;  this  is  usually  para- 
plegia, and  the  sphincters  may  be  also  involved.  Monoplegia  and 
hemiplegia  are  sometimes  found ;  total  motor  and  sensory  paralysis 
foi:  four  limbs  and  the  trunk  may  be  produced. 

Treatment.  The  prophylaxis  consists  in  short  hoijrs  of  work; 
the  forbidding  of  alcohol  for  workers ;  and  slow  decompression. 
When  the  disease  appears,  the  patient  may  be  gradually  subjected 
to  a  pressure  greater  than  that  to  which  he  has  previously  been  sub- 
mitted for  a  short  time,  then  be  decompressed  with  extreme  slow- 
ness— a  day  or  more  may  be  devoted  to  this  process,  if  the  disease 
resulted  from  very  high  pressure.  Under  the  high  pressure,  the 
blood  again  takes  up  the  air  bubbles,  and  under  the  extremely 
gradual  decompression,  this  is  all  breathed  out  through  the  lungs, 
as  is  to  be  desired.  If  this  decompression  is  done  immediately, 
recovery  may  be  absolute;  the  longer  the  delay  in  initiating  the 
treatment,  the  greater  is  the  tissue  destruction. 


LANDRY'S  PARALYSIS 

This  is  a  disease  of  adults  characterized  by  a  very  sudden  and 
acute  onset,  ascending  flaccid  paralysis  of  the  leg,  thigh,  abdomen, 
thorax  and  arms  and  neck.  It  is  probably  due  to  some  infectious 
agent. 

Etiology.  The  disease  is  somewhat  more  frequent  during  an 
epidemic  of  infantile  paralysis,  and  this  together  with  simultaneous 
incidence  of  the  two  diseases  in  the  same  household  has  led  to 
the  inference  that  it  may  be  due  to  the  same  organism.  On  the 
other  hand  no  relationship  can  be  established  in  most  cases.  The 
disease  appears  between  the  twentieth  and  fortieth  year  for  the 
most  part.  Men  are  more  often  afifected  than  women.  There  is 
no  reason  for  supposing  that  the  disease  is  due  to  any  previous 
infection,  though  it  has  been  reported  in  adults  who  had  had 
infantile  paralysis  in  childhood.  In  a  few  cases  the  symptoms  of 
Landry's  paralysis  may  appear  in  the  terminal  stage  of  typhoid, 
pneumonia,  or  other  infectious  diseases. 

Pathology.  The  spinal  cord  shows  all  the  usual  symptoms  of  an 
acute  inflammatory  process  involving  particularly  the  anterior  horn  cells ;  this 
is  practically  identical  with  the  change  in  the  anterior  gray  matter  in  infantile 
paralysis. 


364  THE  SPINAL  CORD 

Diagnosis.  The  disease  begins  very  suddenly.  Fever,  nausea, 
sense  of  weakness,  and  malaise  appear  first.  Weakness  of  the  legs 
is  speedily  followed  by  paralysis  and  this  v^^eakness  and  paralysis 
involve  successively  muscles  of  the  thigh,  the  abdomen,  the  arms 
and  the  neck.  The  foot  is  rarely  affected.  The  muscles  are  atonic 
and  the  reflexes  are  lost.  No  sensory  disturbances  are  present  in 
typical  cases.  There  is  no  loss  of  control  of  the  sphincters.  The 
mind  remains  clear  until  death.  When  the  paralysis  involves  the 
thoracic  muscles,  respiration  is  managed  through  the  action  of  the 
diaphragm  alone;  then,  when  the  cervical  segments  are  affected, 
the  paralysis  of  the  diaphragm  causes  death.  The  heart's  action 
is  not  affected  and  life  may  be  maintained  even  for  hours  by  the 
use  of  artificial  respiration.  Death  usually  results  in  a  few  days. 
Rarely  the  patient  may  live  and  the  later  symptoms  produced 
resemble  acute  ascending  myelitis.  Rarely  sensory  symptoms  are 
present,  such  as  numbness,  tingling  and  cramps  in  the  affected 
muscles.  These  are  no  doubt  partly  due  to  the  effects  produced  in 
the  muscles  and  their  action  upon  the  sensory  nerve  endings  in  the 
muscles  themselves  or  it  may  be  that  the  sensory  disturbances  are 
due  to  the  involvement  of  the  posterior  gray  matter  of  the  spinal 
cord. 

Treatment.  Whatever  manipulative  work  is  indicated  during 
the  acute  attack  should  be  carried  out  with  special  care.  Patients 
suffering  from  this  disease  should  be  isolated.  Since  the  infectious 
agent  is  not  known  the  sick  room  should  be  carefully  screened 
from  flies  and  the  patient  protected  from  insects.  All  excre- 
tions including  those  from  the  nose  and  throat  as  well  as  urine 
and  feces  should  be  thoroughly  destroyed.  The  room  should  be 
disinfected  after  the  death  or  recovery  of  the  patient,  just  as  if 
he  had  suffered  from  any  of  the  ordinary  infectious  diseases.  The 
fever  should  be  controlled  by  the  ordinary  treatment  and  by 
gentle  baths  of  tepid  water.  Great  care  must  be  used  to  pre- 
vent having  the  water  cold  enough  to  produce  any  shock  to  the 
sensory  nerves.  Sponging  with  water  of  the  temperature  of  the 
body  reduces  the  fever  and  frequent  repetitions  of  this  are  much 
better  than  the  use  of  water  which  is  too  cool.  Patients  should 
be  induced  to  lie  either  upon  the  face  or  in  the  right  or  left  lateral 
position  in  order  that  the  force  of  gravity  may  help  to  prevent 
congestion  of  the  spinal  cord.  The  dorsal  decubitus  should  be 
avoided  if  possible  in  this  as  in  all  spinal  cord  disease.  Solid 
food  should  not  be  given.  Water  and  fruit  juices  should  make 
the  most  of  the  diet  permitted.  If  the  patient  recovers  from  the 
acute  disease  the  methods  of  treatment  advised  for  infantile 
paralysis  and  for  myelitis  may  be  adapted  to  his  particular  par- 
alytic symptoms. 


MUSCULAR  ATROPHY  365 

Prognosis.  This  is  always  grave.  Death  may  be  expected 
within  a  week  or  in  two  weeks  at  most.  Complete  recovery  is 
never  to  be  expected  and  the  remaining  paralysis  is  always  serious. 


SPINAL  PROGRESSIVE  MUSCULAR  ATROPHY 

The  various  diseases  which  are  chiefly  characterized  by  slowly 
progressing  atrophy  of  skeletal  muscles  present  so  many  similar 
features  that  they  may  be  discussed  together,  with  only  various 
factors  of  differentiation  mentioned  in  detail.  Atrophy  of  muscles 
may  be  due  either  to  disease  or  degeneration  of  the  muscle  itself, 
as  in  the  muscular  dystrophies ;  or  to  diseases  of  the  nerve  trunk, 
as  in  multiple  neuritis;  or  to  diseases  of  the  cells  in  the  anterior 
horns  of  the  spinal  cord,  as  in  infantile  paralysis  or  the  ordinary 
form  of  progressive  muscular  atrophy ;  or  to  diseases  of  the 
descending  cerebrospinal  tracts  which  in  turn  produce  atrophy  of 
the  anterior  horn  cells,  as  in  amyotrophic  lateral  sclerosis. 

Spinal  progressive  muscular  atrophy  includes  a  class  of  dis- 
eases in  which  the  atrophy  of  the  anterior  horn  cells  of  the  spinal 
cord  is  responsible  for  atrophy  of  the  nerve  fibers  jand  of  the 
muscles  supplied  by  them.  The  features  which  distinguish  the 
various  diseases  included  under  this  generic  term  depend  upon  the 
area  of  spinal  cord  first  afifected  and  the  manner  in  which  the  dis- 
ease extends  to  other  nerve  centers. 

The  most  common  is  the  Duchenne-Aran  type.  In  this  disease 
the  atrophy  begins  in  the  anterior  horns  of  the  cervical  thoracic 
cord  which  gives  origin  to  the  seventh  and  eighth  cervical  and 
the  first  thoracic  nerves ;  weakness  of  the  hands  is  thus  one  of  the 
first  symptoms.  The  thenar  and  hypothenar  eminences  diminish 
in  size.  The  interossei  and  lumbricales  slowly  weaken  and  disap- 
pear. The  shoulder  muscles  are  next  atrophied  and  the  disease 
extends  very  slowly  to  the  upper  arm  and  to  the  trunk  muscles. 
Death  usually  occurs  from  some  intercurrent  disease  but  after 
years  of  slow  progression  the  atrophy  may  involve  the  respiratory 
muscles  thus  leading  to  death. 

Duchenne's  Subacute  Ascending  Paralysis.  This  form  begins 
in  the  lumbosacral  region  of  the  cord  and  thus  the  muscles  of  the 
feet  are  first  afifected.  The  disease  involves  next  the  muscles  of  the 
thigh,  then  of  the  leg.  It  ascends  to  the  trunk  muscles  as  the 
disease  ascends  through  the  nerve  centers  in  the  cord.  Ultimately 
death  results  from  paralysis  of  the  respiratory  muscles,  unless  some 
intercurrent  disease,  usually  pulmonary,  interferes  with  the  par- 
alytic course  of  events.  The  progress  of  this  disease  is  more 
rapid  than  in  the  case  of  the  Duchenne-Aran  type  as  is  indicated 
by  the  term  "subacute." 


366  THE  SPINAL  CORD 

A  third  type  (Erb),  which  is  more  rare  in  this  country,  begins 
also  in  the  lumbosacral  region  and  affects  the  peroneal  muscles 
and  the  anterior  tibial,  but  does  not  extend  to  the  arms,  though  it 
may  involve  most  of  the  leg  and  thigh  muscles.  This  disease  is 
extremely  slow  and  may  remain  stationary  for  several  years.  It 
practically  never  causes  death  except  indirectly,  from  accidents 
due  to  paralysis. 

Progressive  Bulbar  Palsy  may  be  included  in  this  group  also. 
In  this  disease  the  atrophy  begins  in  the  motor  nuclei  of  the 
medulla.  There  are  difficult  speech,  drooling,  dysphagia,  which 
may  go  on  to  complete  inability  to  speak,  swallow  or  close  the 
lips.  The  mentality  is  not  aifected.  The  heart  is  very  weak  and 
rapid  and  death  is  due  to  complete  failure  of  the  heart  or  starva- 
tion or  suffocation,  or  all  three  combined. 

A  number  of  other  variations  in  type  have  been  described,  with 
slightly  different  symptoms.    These  are  all  very  rare. 

Pathology.  The  pathology  of  all  these  diseases  is  practically  identi- 
cal, a  chronic  anterior  poliomyelitis.  The  nerve  cells  in  the  anterior  horns  of 
the  spinal  cord  undergo  a  very  slow  atrophy.  There  is  no  chromatolysis,  no 
extrusion  of  the  nuclei,  no  swelling,  no  pigmentation,  and  no  degeneration  in 
the  ordinary  sense  of  the  word.  The  cell-body  shows  first  merely  an  increased 
pericellular  lymph  space.  Later  the  body  of  the  cell  diminishes.  The  nucleus 
diminishes  in  size  and  takes  the  stain  more  lightly  than  under  normal  conditions. 
This  process  goes  on  until  nothing  is  left  of  the  nerve  cell  or  of  the  axon  which 
arises  from  it.  The  neuroglia  proliferates,  filling  up  the  space  left  by  the  dis- 
appearing nerve  cell.  The  spinal  cord  in  an  old  case  may  show  almost  no 
trace  of  the  nerve  tissue  in  the  anterior  horns.  The  columns  of  Clarke  and 
the  posterior  horns  remain  unaffected.  The  nerve  trunks  share  in  the  atrophy; 
there  is  no  recognizable  proliferation  of  the  connective  tissue  cells  of  the  nerve 
trunk. 

Sections  of  the  muscles  during  the  process  of  atrophy  show  a  granular 
muscle  protoplasm  followed  by  a  deposit  of  fine  fatty  granules.  Occasionally  a 
single  hypertrophic  muscle  fiber  may  appear.  The  atrophy  of  the  muscle  is 
very  complete  and  ultimately  only  a  shred  of  connective  tissue  may  mark  its 
original  site.  Usually  bony  lesions  are  found  in  close  central  connection  with 
the  spinal  area  involved,  but  it  is  not  possible  to  say  whether  these  are  primary 
or  secondary. 

Etiology.  Practically  nothing  is  known  of  the  real  cause  of 
this  disease.  It  begins  in  middle  life,  rarely  appearing  before  the 
age  of  thirty.  It  is  found  in  adults  who  have  suffered  from  infan- 
tile paralysis  in  childhood,  but  perhaps  not  more  frequently  than 
the  law  of  averages  would  explain.  Occasionally  it  seems  to  date 
from  some  infectious  disease,  and  sometimes  from  pregnancy, 
especially  from  very  frequent  pregnancies.  Alcoholism  and  syph- 
ilis are  not  probable  factors. 

The  place  of  the  bony  lesion  has  already  been  mentioned.  The 
presence  of  bony  and  muscular  lesions  associated  with  the  spinal 
centers  first  involved  is  probably  invariable  but  whether  these  are 
localizing  factors  in  the  disease  or  whether  they  are  really  impor- 
tant in  etiology  or  whether  they  are  merely  soine  of  the  effects 


LATERAL  SCLEROSIS  367 

of  the  disease  acting  through  the  spinal  muscles  cannot  yet  be 
determined. 

The  diagnosis  depends  upon  the  history  of  a  slow  and  gradually 
increasing  muscular  atrophy  with  no  sensory,  bladder  or  erectile 
symptoms.  It  is  distinguished  from  progressive  muscular  dys- 
trophy in  the  fact  that  this  disease  appears  in  childhood,  and  is 
associated  with  hereditary  or  family  history ;  has  no  fibrillary 
tremors  and  has  usually  an  individual  history  and  an  early  hyper- 
trophy. 

Laboratory  tests  and  X-radiance  throw  some  light  upon  the 
diagnosis.  Fibrillary  tremors  are  present  during  the  early  stages. 
There  may  be  pains  in  the  muscles  themselves  which  are  apparently 
due  to  the  fatigue  of  the  weakened  muscles  being  used  as  if  they 
were  normal. 

No  treatment  seems  to  affect  the  course  of  the  disease  in  any 
really  efficient  way.  In  correcting  the  bony  lesions  great  care 
must  be  exercised  to  prevent  irritation  of  the  sensory  nerveS  dis- 
tributed to  the  skin,  muscles  and  articular  surfaces  which  are  in 
close  sensory  connection  with  the  trophic  area.  This  work  very 
slowly  and  gently  accomplished  seems  to  delay  the  progress  of 
the  disease  in  most  cases.  In  a  few  cases  such  treatments  given 
once  each  week  or  once  in  two  weeks  through  several  years  have 
been  associated  with  relief  of  the  symptoms  while  the  disease 
seems  to  progress  less  rapidly.  Perhaps  in  cases  seen  very  early 
thorough  treatment  will  be  successful. 

Rest  should  be  given  the  affected  muscle  groups  and  ordinary 
good  hygienic  conditions  should  be  maintained.  Some  authors 
advise  hot  applications  to  the  muscles  involved.  Mild  stimulation 
by  static  electricity  and  frequent  gentle  massage  of  the  affected 
muscles  are  useful  in  some  cases,  though  these  agents  appear  in 
other  cases  to  increase  the  rapidity  of  the  atrophy. 

Prognosis.  Recovery  is  probably  impossible  since  the  atrophy 
of  the  muscles  and  of  the  nerve  cells  innervating  them  is  complete. 
The  disease  may  remain  stationary  for  some  ye^rs  at  almost  any 
time.  It  is  not  likely  to  cause  death  unless  the  atrophy  involves 
the  trunk  muscles  or  the  bulbar  centers.  When  the  paralysis 
involves  the  legs  it  may  lead  to  accidents.  Pulmonary  affections 
usually  give  the  terminal  chapter  in  the  story  of  this  disease. 

AMYOTROPHIC  LATERAL  SCLEROSIS 

Amyotrophic  lateral  sclerosis  is  a  disease  of  the  spinal  cord 
characterized  by  atrophy  of  the  descending  pyramidal  tracts,  sec- 
ondary atrophy  of  the  anterior  horns  of  the  cord  and  a  slowly 
progressive  muscular  paralysis  and  atrophy. 

Pathology.  The  fact  that  the  disease  begins  in  the  lateral  tracts  ip 
most  cases  is  demonstrated  by  numerous  autopsies,  though  for  a  long  time  it 


368  THE  SPINAL  CORD 

was  supposed  that  the  anterior  horn  cells  were  primarily  degenerated  and  that 
the  atrophy  of  the  lateral  tracts  appeared  as  a  secondary  phenomenon.  Exam- 
ination of  the  spinal  cord  of  the  patient  who  has  suffered  from  this  disease 
shows  that  the  atrophy  of  the  lateral  tracts  begins  at  the  end  of  each  individual 
axon,  extending  upward.  The  atrophy  does  not  usually  pass  the  medulla,  though 
in  a  few  instances  it  has  been  traced  to,  and  involving,  the  larger  pyramidal 
cells  in  the  precentral  convolution. 

Etiology.  The  cause  of  the  disease  is  not  known.  It  is  prob- 
ably to  be  included  among  the  abiotrophic  diseases.  The  nerve  cells 
are  not  reproduced  during  life  so  far  as  our  present  knowledge 
goes,  and  when  any  given  cell  is  subjected  to  a  greater  amount  of 
use  or  to  less  than  the  conditions  required  for  its  proper  nutrition 
then  progressively  increasing  inefficiency  must  result.  Such  a  cell 
shows  senile  changes.  These  may  become  evident  either  in  the 
cell  body  or,  as  in  the  case  of  amyotrophic  lateral  sclerosis,  by  a 
diminution  of  function  followed  by  an  atrophy  which  most  com- 
monly shows  disease  first  in  those  parts  of  the  protoplasm  most 
distant  from  the  nucleus  of  the  neuron.  Atrophy  of  the  lateral 
tracts  may  follow  anything  which  separates  these  fibers  from  their 
cell  body.  Direct  injury  to  the  spinal  cord  such  as  may  be  pro- 
duced by  wounds  or  other  trauma,  or  by  tumors,  which  may  exert 
pressure  upon  the  spinal  cord,  tumors  or  abscesses,  tubercles  or 
gumma,  hemorrhages  or  any  other  pathological  changes  in  the 
brain  itself  or  in  any  part  of  the  pathway  traversed  by  the  pyra- 
midal axon  may  result  in  the  atrophy  of  the  crossed,  or  more 
rarely,  the  direct  pyramidal  tracts  and  thus  to  the  development  of 
the  disease  referred  to.  In  pernicious  anemia  and  in  multiple 
sclerosis  paralysis  of  this  type  iriay  be  one  of  the  earliest  and 
most  conspicuous  symptoms. 

There  is  no  reason  to  suppose  that  syphilis  is  an  important 
factor.  Probably  anything  which  lowers  the  nutrition  of  the  body 
as  a  whole  or  which  interferes  especially  with  the  nutrition  of  the 
spinal  cord  may  act  as  an  exciting  or  predisposing  factor  in  the 
development  of  this  as  in  any  other  nervous  disease. 

The  place  of  heredity  in  this  disease  has  been  very  much  dis- 
cussed. There  seems  no  doubt  that  there  is  a  tendency  for  the 
disease  to  appear  among  members  of  the  same  family  and  also  to 
be  interchangeable  in  inheritance  with  several  other  diseases  of  the 
central  nervous  system. 

Diagnosis.  The  disease  usually  appears  first  in  the  lower  part 
of  the  body,  perhaps  because  the  crossed  pyramidal  tracts  are 
made  up  of  the  longest  fibers.  There  is  at  first  a  stiffness  in  the 
muscles  involved  which  is  associated  with  an  increase  in  the 
muscular  tone.  Reflexes  are  increased.  Paralysis  may  involve  the 
hands  first  of  all  in  which  case  the  small  muscles  are  first  paralyzed 
and  the  disease  follows  the  path  of  the  Duchenne-Aran  type. 
Fibrillary  contractions  are  present.    Reflexes  are  increased ;  ankle 


•    LATERAL  SCLEROSIS  369 

clonus  and  Babinski  are  present.  There  is  a  spastic  gait.  The 
legs  may  cross  in  walking,  giving  rise  to  a  "scissor's  gait,"  which 
is  rarely  very  pronounced.  The  disease  is  usually  bilateral,  but 
one  leg  may  be  first  involved.  There  are  no  bladder  or  rectal 
symptoms.  As  the  process  of  atrophy  extends  the  muscles  are 
progressively  involved.  When  the  disease  affects  the  bulbar  cen- 
ters the  muscles  of  the  lips,  tongue,  palate  and  throat  are  par- 
alyzed and  later  atrophied.  Fibrillary  twitchings  are  prominent 
symptoms  of  the  beginning  of  this  atrophy.  The  patient's  speech, 
deglutition,  and  mastication  become  increasingly  difficult.  The 
face  becomes  flat  and  expressionless  after  the  completion  of  the 
paralysis.  Rarely  the  eye  muscles  are  involved.  Intelligence  is 
not  affected.  When  the  atrophy  extends  above  the  medulla  there 
is,  as  in  bulbar  palsy,  a  tendency  to  excessive  emotional  expression, 
so  that  the  patient  laughs  and  cries  more  extravagantly  than  is 
usual  among  normal  individuals.  The  cause,  of  this  excessive 
emotionalism  is  not  known.  It  is  a  source  of  considerable  annoy- 
ance to  those  patients  whose  knowledge  of  their  own  condition  is 
decidedly  acute.  There  is  very  good  reason  to  believe  that  the 
integrity  and  development  of  the  motor  system  as  a  whole  is 
directly  associated  with  those  psychological  qualities  commonly 
included  in  the  expression  "self-control." 

Tachycardia  is  a  fairly  constant  symptom.  Death  may  occur 
from  some  intercurrent  infection  usually  of  the  lungs,  or  starva- 
tion may  result  from  the  bulbar  effects. 

Treatment.  The  osteopathic  treatment  must  be  planned  to 
secure  the  best  circulation  through  the  spinal  cord  and  the  muscles 
as  well  as  to  keeping  up  the  general  circulation  and  nutrition  of  the 
entire  body.  Since  nervous  diseases  of  this  type  seem  to  follow 
Mendel's  law  persons  from  neurotic  families  should  be  strongly 
advised  against  intermarriage.  When  one  parent  comes  of  a 
family  in  which  this  or  other  nervous  diseases  of  an  abiotrophic 
type  have  been  present  every  care  should  be  exercised  to  guard  the 
children  from  causes  of  malnutrition.  Their  life  should  be  more 
than  usually  hygienic.  No  strain,  overwork  or  excitement  should 
be  permitted.  Not- only  while  they  are  children  but  also  when 
they  have  reached  adult  life  they  must  live  normally  hygienic  lives 
if  they  are  to  avoid  falling  a  victim  to  this  or  some  other  serious 
nervous  disease. 

After  the  onset  of  the  symptoms  the  general  health  is  to  be 
kept  up  in  every  way.  Stimulation  of  the  muscles  by  mild  mas- 
sage or  by  electrical  and  thermal  stimulation  seem  Sometimes  to 
be  of  some  use.  When  there  is  difficulty  in  swallowing  it  is  better 
to  give  all  food  and  drink  through  the  stomach  tube  in  order  to 
avoid  the  danger  of  aspiration  pneumonia. 


370  THE  SPINAL  CORD 

Prognosis.  Probably  no  recovery  is  possible.  The  best  that 
can  be  hoped  for  is  to  somewhat  delay  the  progress  of  the  disease 
and  possibly  to  cause  it  to  become  stationary. 

HEREDITARY  SPINAL  ATAXIA 

There  is  a  group  of  abiotrophic  diseases  which  are  variously  described  by 
different  authors  and  which  present  symptoms  which  vary  to  a  certain  extent 
and  have  resemblances  which  are  sometimes  quite  marked.  By  some  authors 
the  term  Friedreich's  ataxia  is  apphed  to  the  entire  group  of  hereditary  ataxias, 
which  are  characterized  by  symptoms  referable  to  degeneration  of  the  posterior 
funiculi  of  the  cord.  The  description  given,  however,  seems  to  apply  especially 
to  the  spinal  cord  type  of  diseases,  while  the  cerebellar  form  has  been  best 
studied  by  Marie. 

The  disease  is  invariably  hereditary  or  familial.  The  ataxia  appears  from 
the  third  to  the  ninth  year.  It  involves  the  legs  and  the  arms  about  equally. 
At  first,  the  children  appear  merely  to  be  awkward;  they  walk  with  straddling 
gait,  and  the  feet  are  turned  in  somewhat  the  position  of  varo-equines ;  the 
child  drops  things,  spills  fluids  he  is  trying  to  carry,  knocks  things  from  the 
table,  falls,  and  appears  generally  to  be  awkward  and  careless ;  as  the  condition 
grows  worse,  it  becomes  evident  that  it  is  a  disease  rather  than  a  bad  habit 
from  which  he  suffers ;  the  facial  muscles  and  the  respiratory  muscles  may  be 
involved  in  the  later  stages ;  with  constant  effort  some  of  these  children  learn 
to  walk  and  to  handle  themselves  fairly  well.  A  kyphosis  or  kypho-scoliosis  is 
almost  always  present.  Nystagmus  is  bilateral.  Stuttering  speech  is  followed  by 
■^an  unintelligible  jargon.    Intelligence  may  not  be  affected. 

The  pathological  changes  include  degeneration  of  the  posterior  funiculi, 
atrophy  of  the  cells  in  the  dorsal  nucleus  (Clarke's  column),  and  of  some  of 
the  cells  in  the  posterior  root  of  the  ganglia,  and  some  of  the  fibers  in  the 
peripheral  nerves. 

Recovery  is  impossible.  The  disease  does  not  shorten  life,  unless  some 
accident  should  occur  as  the  result  of  the  incoordination.  One  family  was  kept 
under  observation  for  several  years  in  the  Pacific  College  Clinic.  Attempts 
were  made  to  correct  the  kyphosis  but  without  success.  No  good  results  from 
the  treatment  were  perceptible. 


CHAPTER  XXXVI 
DISEASES  OF  THE  BRAIN 

GENERAL  DISCUSSION 

The  diseases  to  which  the  brain  is  subject  appear  Jo  be  due 
for  the  most  part  to  variations  in  its  circulation  and  to  the  effects 
of  bacteria  and  of  various  poisons.  There  is  no  reason  whatever 
for  supposing  that  any  brain  disease  is  due  to  overwork  except  as 
too  long  continued  devotion  to  work  may  lessen  the  hours  of 
sleep  and  exercise,  or  the  food  necessary  to  the  maintenance  of 
a  good  circulation  of  good  blood ;  in  other  words,  in  all  cases  in 
which  overwork  is  considered  a  cause  of  brain  disease  it  is  far 
more  probable  that  it  is  the  poor  nutrition,  the  lack  of  oxygen  or 
the  presence  of  toxic  materials  in  the  blood  that  is  responsible  for 
the  brain  disease  rather  than  any  overactivity  of  the  brain  tissue. 

The  brain  is  supplied  by  terminal  arteries ;  vasomotor  nerves 
are  known  to  be  supplied  to  these  and  to  originate  for  the  most 
part  in  the  superior  cervical  sympathetic  ganglia  which  in  turn 
receives  its  control  from  the  first  to  the  fifth  thoracic  segments  of 
the  cord.  Bony  lesions  in  this  area  may  thus  modify  the  circula- 
tion through  the  brain  to  a  certain  extent.  By  far  the  most  impor- 
tant factors  in  controlling  the  arterial  supply  to  the  brain,  however, 
are  the  conditions  which  modify  the  general  blood  pressure. 

Infection  of  the  brain  itself  extends  from  meninges  in  most 
cases.  As  in  the  case  of  the  spinal  neurons  the  extreme  irritability 
which  gives  the  brain  its  value  in  function  renders  it  also  extremely 
subject  to  the  effects  of  poisons  in  the  circulating  blood.  Poisons 
as  well  as  bacteria  seem  to  have  a  selective  action  upon  certain 
parts  of  the  central  nervous  system.  This  is  especially  noticeable 
in  the  effects  produced  by  the  syphilitic  toxins,  lead,  mercury,  the 
bacteria  responsible  for  anterior  poliomyelitis  and  the  protozoa 
responsible  for  rabies. 

Circulatory  disturbances  may  be  due  to  poisons,  in  which  case 
they  most  frequently  occur  during  middle  life ;  or  to  birth  injuries, 
in  which  case  the  symptoms  occur  during  the  first  year  or  the 
first  decade  of  life;  or  to  senile  diseases  of  the  blood  vessels,  in 
which  case  the  disease  occurs  after  the  sixtieth  year.  Functional 
nervous  diseases  are  associated  with  the  time  of  life  during  which 
the  nervous  relationships  and  neuronic  development  are  under- 
going most  pronounced  changes  and  are  thus  especially  frequent 
during  the  period  of  adolescence  or  during  the  climacteric  period. 

371 


372  THE  BRAIN 

CEREBRAL  ANEMIA 

This  condition  occurs  secondarily  in  a  number  of  other  dis- 
orders. It  is  characterized  by  nausea,  sometimes  vomiting,  and 
dizziness,  vertigo,  or  syncope.  'Mania  or  delirium  may  occur.  A 
mild  degree  of  anemia  is  present  during  normal  sleep. 

General  anemia,  such  as  occurs  after  large  hemorrhage  any- 
where in  the  body,  is  associated  with  cerebral  anemia  also. 

In  cachectic  diseases,  with  primary  or  secondary  anemia,  the 
brain  shares  in  the  bloodlessness.  Varying  mental  disturbances 
may  result;  drowsiness  and  stupor,  even  to  coma;  mania  and 
delirium,  or  only  a  diminished  interest  and  ambition,  are  the  results 
of  the  starvation  and  poisoning  that  are  caused  by  a  deficient  cir- 
culation of  poor  blood  through  the  brain. 

Ordinary  fainting,  or  syncope,  is  due  to  overfilling  of  the 
splanchnic  vessels  with  blood;  under  certain  emotional  disturb- 
ances, fright,  horror,  disgust,  rarely  anger  or  delight,  the  vaso- 
motor centers  controlling  the  liver,  intestines,  and  spleen  appear 
to  be  paralyzed,  and  these  organs  are  filled  with  blood;  the  mus- 
cular wall  of  the  spleen  and  the  muscles  of  the  intestines  are  also 
relaxed.  The  first  condition  adds  to  the  cerebral  ischemia;  the 
second  adds  to  the  ischemia  and  also  permits  carbondioxid  gas  to 
be  set  free  in  the  intestines  in  considerable  amounts. 

Treatment  is  usually  devoted  to  the  underlying  cause  of  the 
bloodlessness.  Anemias  must  be  treated  according  to  the  causes 
of  this  condition.  In  ordinary  syncope,  the  head  must  be  lower 
than  the  reclining  body,  and  sensory  stimulation,  sprinkling  of 
cold  water,  rubbing  the  hands,  smelling  salts,  etc.,  are  all  useful. 
If  the  heart  is  weak,  stimulating  manipulations  around  the  fourth 
thoracic  spine,  and  in  the  left  fifth  interspace  anteriorly,  hasten 
its  return  to  normal. 

Another  form  of  cerebral  anemia  is  produced  by  pressure;  overfilling  of 
the  meningeal  vessels  or  the  venous  sinuses,  or  tumor,  or  serous  meningitis,  or 
cerebral  edema,  all  cause  an  ischemia  of  all  or  part  of  the  brain  substance.  In 
these  cases,  the  symptoms  produced  vary  greatly. 


CEREBRAL  HYPEREMIA 

Active  hyperemia,  aside  from  the  primary  stage  of  inflamma- 
tory process,  is  not  certainly  known  to  exist  in  the  brain.  The  fact 
that  the  vasomotor  nerves  of  the  brain  are  comparatively  ineffi- 
cient, and  that  the  circulation  is  chiefly  dependent  upon  variations 
in  the  general  blood  pressure,  seems  demonstrated  by  clinical  and 
by  experimental  evidence.  The  rigidity  of  the  skull  also  prevents 
the  facile  variations  in  circulation,  in  functional  activity,  that  is 
found  in  glands  and  other  active  tissues  of  the  body.  Transient 
apoplectiform  attacks  may  be  due  to  the  sudden  local  hyperemia  of 
the  brain,  and  these  are  best  treated  by  elevating  the  head,  inhib- 


APOPLEXY  373 

iting  the  splanchnics,  and  the  application  of  ice  bags  to  the  head. 
The  old  tendency  to  consider  hyperemia  of  the  brain  present  when 
the  face  is  red  and  congested,  is  now  known  to  be  fallacious. 

Passive  congestion  of  the  brain  may  be  caused  by  pressure  upon 
the  jugular,  the  innominate,  or  the  vena  cava,  or  by  tricuspid  lesion. 
It  is  characterized  by  constant,  dull  headache,  somnolence  and 
sometimes  mental  torpor.  The  treatment  includes  removing 
the  pressure  upon  the  veins,  in  the  one  case,  and  inhibition  of 
the  splanchnics,  correction  of  muscular  and  bony  lesions  which 
may  interfere  with  the  circulation  in  any  way,  and,  in  generalj 
relieving  the  burden  upon  the  heart,  in  the  other. 

CEREBRAL  EDEMA 

Passive  congestion  of  the  brain  may  cause  edema.  Nephritis, 
blood  diseases,  heart  diseases,  cause  edema  of  the  brain,  as  of  other 
organs.  Angio-neurotic  ederiia  may  affect  the  brain,  either  locally 
or  generally ;  death  may  result  from  this  disease.  Alcoholism, 
especially,  may  cause  a  form  of  "wet  brain"  probably  an  over- 
secretion  of  the  cerebrospinal  fluid  as  the  result  of  an  inflammatory 
process  (see  serous  meningitis).  Certain  other  forms  of  menin- 
gitis may  be  associated  with  an  increase  in  the  cerebrospinal  fluid, 
but  these,  as  hydrocephalus,  may  not  be  associated  with  any  in- 
creased amount  of  waiter  either  between  or  within  the  brain  cells. 

Edema  of  the  brain  cannot  be  certainly  diagnosed  ante-mortem, 
but  may  be  suspected  when  the  symptoms  of  increased  intracranial 
pressure  appear  together  with  any  of  the  etiological  factors  just 
mentioned. 

The  treatment  is  that  of  the  causative  factors,  plus  measures 
toward  equalizing  the  circulation  of  the  blood,  and  especially  facil- 
itating the  drainage  from  the  cranial  cavity.  Correction  of  all 
abnormal  structural  relations  in  the  cervical  region,  anteriorly  and 
posteriorly,  and  such  manipulations  as  may  be  required  to  give 
plenty  of  room  in  the  thoracic  inlet,  are  the  most  important  factors. 
The  treatment  must  include  good  hygiene  and  frequently  some 
special  diet,  adapted  to  the  patient's  general  condition. 

APOPLEXY 

The  term  is  limited  by  some  authors  to  cerebral  hemorrhage; 
the  impossibility  of  making  ante-mortem  diagnosis  between  hem- 
orrhage, thrombosis,  and  embolism,  and  the  close  relation  between 
these  accidents  in  their  pathological,  etiological,  and  clinical  sig- 
nificance has  led  to  the  broader  definition  of  the  word.  Apoplexy 
is  a  circulatory  accident  occurring  in  the  brain,  and  characterized 
by  sudden  onset  of  paralysis,  with  varying  degrees  of  unconscious- 
ness. 


374  THE  BRAIN 

Cerebral  hemorrhage  includes  also  meningeal  hemorrhage,  inso- 
far as  this  produces  cerebral  insult  and  symptoms  of  apoplexy.  At 
the  time  of  birth,  and  for  a  few  months  after,  cerebral  hemorrhage 
is  rather  frequent;  after  this  period  it  is  rare  until  the  time  of 
arterial  degeneration.  Hemorrhagic  diseases,  as  scurvy,  "black" 
infectious  diseases,  etc.,  may  be  associated  with  cerebral  hem- 
orrhage; such  cases  are  rare,  and  may  occur  at  any  time  of  life. 
After  the  age  of  fifty,  arteriosclerosis  is  by  far  the  most  common 
cause  of  apoplexy.    Syphilitic  endarteritis  is  a  frequent  cause. 

By  far  the  greater  number  of  cases  are  due  to  rupture  of  small 
aneurysms ;  and  this  most  frequently  occurs  in  the  left  lenticulo- 
striate  artery.  This  fact  is  due  to  the  anatomical  relations  of  the. 
branches  of  the  aorta;  the  most  direct  path  of  the  cardiac  force 
leads  from  the  left  ventricle  to  this  artery.  For  the  same  reason, 
the  middle  cerebral  artery,  in  some  of  its  branches,  is  most  often 
the  seat  of  embolism. 

Injury  to  the  head,  as  a  blow,  may  cause  rupture  of  the  vessels ; 
this  may  occur  upon  the  surface  of  the  brain,  or  within  its  sub- 
stance, according  to  the  location  and  force,  and  the  manner  in 
which  the  blow  falls  upon  the  skull.  It  must  be  remembered 
that  the  brain,  during  life,  is  almost  fluid  in  consistency,  and 
that,  like  other  fluids,  it  transmits  force,  undiminished,  in  every 
direction.  The  structural  injury  produced  by  a  blow  with  a  soft 
or  elastic  object  is  the  resultant  of  many  varying  lines  of  force. 
The  destroyed  area  may  be  upon-  the  opposite  side  of  the  brain,  or 
upon  some  area  in  the  basal  ganglia,  where  the  lines  of  force  meet 
or  cross.  Such  distant  injuries  are  said  to  be  produced  from 
"contre  coup."  Disintegration  of  the  brain  substance  may  follow 
such  a  shock,  and  this  may  result  in  weakening  a  blood  vessel, 
which  ultimately  yields  to  some  slight  variation  in  the  blood  pres- 
sure ;  this  is  called  "delayed  apoplexy." 

The  term  "apoplectic  habit"  is  applied  to  stout,  heavy-get  peo- 
ple, usually  with  thick  necks  and  red  faces.  When  such  persons 
are  overfed,  alcoholic,  and  deficient  in  self-control,  they  are  decid- 
edly prone  to  apoplexy. 

Capillary  hemorrhages  may  result  from  cerebral  congestion,  or 
from  any  of  the  infectious  diseases ;  they  usually  produce  no 
recognizable  symptoms,  and  are  merely  found  after  death.  Venous 
hemorrhages  may  result  from  injury,  from  the  rupture  of  varicose 
veins,  or  from  passive  congestion  and  emotional  or  muscular  stress. 

In  all  cases,  some  pathological  condition  of  the  cerebral  vessels 
must  be  supposed  to  be  present  if  any  ordinary  change  in  blood 
pressure  initiates  hemorrhage.  This  weakness  being  present,  the 
rupture  may  be  finally  caused  by  anything  which  raises  the  gen- 
eral blood  pressure;  emotional  stress,  coition,  straining  at  stool, 
coughing,  muscular  effort,  as  running  or  lifting,  are  all  causes; 


APOPLEXY  375 

but  many  cases  occur  during  sleep,  and  at  times  of  absolute  quiet 
of  body  and  mind. 

Diagnosis  is  directed  chiefly  to  the  localization  of  the  injury. 
Prodromal  symptoms  are  not  frequent;  there  may  be  headache, 
increased  blood  pressure,  paresthesias,  weakness,  vertigo,  a  vague 
discomfort,  and  a  tendency  toward  awkward  speech  for  a  few  hours 
or  days  before  the  attack.  The  speech  difficulty  attracts  most 
attention,  and  is  rather  diagnostic  of  an  impending  attack,  in  per- 
sons whose  vessels  are  diseased.  The  voice  becomes  slightly 
husky,  the  words  enunciated  more  slowly  but  less  plainly  than 
usual,  and  there  may  be  tendency  to  "forgetfulness"  of  familiar 
words — which  is  really  a  form  of  aphasia — in  such  cases.  The 
symptoms  are  usually  referred  by  the  patient  and  his  family  to 
slight  indigestion.  The  attack  begins  with  unconsciousness  of 
sudden  onset.  The  patient  falls;  breathes  with  stertor;  the 
cheeks  are  relaxed  and  flap;  the  pulse  is  first  feeble,  then 
becomes  full  and  strong ;  the  blood  pressure  is  high ;  the  face 
is  flushed,  often  purple ;  there  may  be  relaxation  of  the  sphincters. 
The  pupils  may  be  contracted  or  dilated  or  normal ;  the  eyes 
and  head  may  or  may  not  be  deviated ;  the  limbs  fall  flabbily 
when  raised.  If  the  hemorrhage  is  in  the  medulla  or  the  fourth 
ventricle  death  usually  occurs  during  this  time.  If  the  temperature 
is  very  high — 106°  or  so — death  is  usually  inevitable  within  a  few 
hours.  If  death  does  not  occur  this  period  passes  away  in  a  few 
hours  to  a  day  or  two.  Consciousness  returns,. more  or  less  com- 
pletely, and  the  extent  of  the  paralysis  is  manifested.  Fever,  delir- 
ium, coma,  with  spasmodic  movements  of  the  muscles  of  the 
affected  and  the  sound  side,  may  persist  for  several  days.  The 
temperature  on  the  paralyzed  side  is  higher,  perhaps  .5°  to  2°, 
than  on  the  normal  side  of  the  body.  Reflexes  are  lost,  at  first,  then 
are  exaggerated.  Speech  is  usually  impossible  for  some  days, 
even  when  the  speech  center  is  not  directly  affected;  mentality 
seems  dulled  for  some  days  after  the  other  symptoms  have  largely 
disappeared.  Within  a  few  days  to  a  few  weeks,  the  effects  may 
have  altogether  disappeared ;  or,  when  the  hemorrhage  has  been 
great,  or  the  locality  affected  of  considerable  importance,  there 
may  be  permanent  paralysis  of  the  side  of  the  body  opposite  to  the 
injury.  The  exact  extent  and  locality  of  the  paralysis  depends 
upon  the  location  and  the  extent  of  the  cerebral  injury. 

In  most  cases,  the  hemorrhage  is  from  the  lenticulo-striate 
artery,  and  affects  the  internal  capsule,  thus,  the  fibers  descending 
from  the  motor  cortex  of  the  left  side.  Injury  to  the  deeper  cerebral 
tracts  involves  the  speech  mechanism.  Lesion  of  the  posterior 
limb  of  the  capsule  causes  sensory  disturbances ;  bilateral  homon- 
ymous hemaniopsia,  somatic  anesthesias,  and  partial  deafness  in 


376  THE  BRAIN 

both  ears  may  thus  be  produced.  Sometimes  muscle  and  thermal 
sensations  are  lost,  but  touch,  vision,  and  audition  are  preserved. 

When  the  hemorrhage  involves  the  pons,  the  pupils  are  con- 
tracted, the  temperature  is  high,  the  face  is  paralyzed  upon  the  side 
of  the  lesion,  and  the  arms  and  legs  upon  the  opposite  side.  When 
the  injury  is  in  the  lower  part  of  the  pons,  the  oculomotor  nerves 
may  be  paralyzed  upon  the  side  of  the  lesion,  and  the  rest  of  the 
face  and  the  limbs  upon  the  opposite  side. 

Cerebellar  hemorrhage  is  rare,  and  is  hard  to  recognize.  If 
one  lobe  is  involved,  no  effects  may  be  produced,  beyond  the  initial 
insult.  Hemorrhage  into  any  of  the  ventricles  is  usually  quickly 
fatal.  Ingravescent  apoplexy  is  characterized  by  the  slow  onset 
of  the  coma ;  it  is  usually  fatal.  A  second  attack,  occurring  before 
recovery  from  the  first,  is  usually  fatal.  If  partial  or  complete 
recovery  occurs  between  attacks,  a  large  number  of  successive 
attacks  may  occur,  without  fatality;  that  the  hemorrhage  will 
ultimately  be  fatal  may  be  granted  in  every  case;  unless  death 
from  some  other  cause  occurs  speedily. 

The  paralysis  produced  is  of  the  upper  neuron  type;  except  as 
hemorrhage  into  the  pons  might  produce  lower  neuron'  paralysis 
of  the  facial  nerve.  Reflexes  are  exaggerated,  but  may  seem  to 
disappear  as  the  result  of  the  contractions.  No  reaction  of  degen- 
eration, or  true  muscular  atrophy  occurs,  though  as  the  result  of 
disuse,  and  the  steady  pull  of  opposing  muscle  groups,  deformity 
and  atrophy  of  the  muscles  may  ultimately  be  noted. 

Occasionally,  hemorrhages  in  other  parts  of  the  brain,  and  the 
effects  of  the  hemorrhage  upon  the  basal  centers  themselves, 
cause  various  choreic  and  athetoid  movements;  instability  of  the 
emotional  states;  easy  laughter  and  weeping;  stammering  and 
stuttering  speech.  The  mental  processes  may  remain  fairly  normal, 
even  with  these  effects,  but  more  frequently  mentality  deteriorates 
steadily.  Epileptiform  attacks  are  even  less  frequent,  especially  in 
nonsylphilitic  cases. 

Embolism.  The  obstruction  of  an  artery  by  materials  carried 
in  the  blood  stream  is  called  embolism ;  the  matter  which  is  carried 
is  an  "embolus,"  or  plug'. 

Pathology.  In  the  brain,  since  the  arteries  are  terminal,  embolism 
"^produces  a  cone-shaped  infarct,  whose  apex  is  the  point  of  obstruction  and 
whose  area  is  that  of  the  distribution  of  the  artery  interrupted.  If  there  is 
overlapping  of  other  arteries,  or  anastomosis  in  any  degree,  the  after-changes 
are  slower,  and  recovery  may  occur.  The  loss  of  the  circulation  may  cause 
recognizable  changes  in  the  nerve  cells  and  fibers  within  a  day;  the  starva- 
tion and  degeneration  of  the  nerve  tissue  is  very  rapid.  When  there  is 
any  hemorrhage  into  the  infarct — and  there  usually  is,  especially  in  gray  matter — 
the  process  is  called  "red  softening."  With  progressive  digestion  of  the 
hemoglobin,  and  with  the  occurrence  of  fatty  degeneration,  especially  in  areas 
which  have  been  hemorrhagic,  the  "yellow  softening"  takes  place.  Infarcts  in 
the  scantily-blooded  white  matter  are  often  colorless — "white  softening"  then 
occurs.    Softening  is  the  same  process,  however,  in  all  colors.    The  nerve  cells 


APOPLEXY  377 

and  fibers  undergo  first  granular,  then  fatty  metamorphosis,  then  are  digested, 
and,  in  time,  absorbed.  A  clear  liquid  is  left,  if  the  softened  area  is  of  some 
size,  which  may  be  slightly  tinged  with  red  or  brownish  color.  The  degenerating 
material  gives  stimulus  to  the  connective  tissues  around  the  blood  vessels,  and 
to  the  neuroglia  of  the  injured  region,  so  that  either  or  both  of  these  tissues 
multiply,  forming  a  wall,  which  surrounds  the  larger  infarcts  and  contains  the 
liquid  remnants  (hemorrhagic  cyst),  or  fills  the  cavities  left  by  the  small  ones 
with  a  scar-like  tissue. 

Etiology.  The  emboli  are  most  frequently  fragments  of  clots 
or  vegetations  from  the  aortic  valves.  Less  frequently  bacteria 
or  fragments  from  an  atheroma  may  become  emboli.  Materials 
from  the  lungs  sometimes  pass  through  the  heart  and  become 
emboli,  these  are  often  infected,  and  thus  the  infarct  is  also  infected 
by  the  same  disease  as  that  of  the  lungs. 

Thrombosis.  Clotting  of  the  blood  in  a  vessel  may  result  in 
complete  obstruction ;  this  process  is  called  "thrombosis" ;  the  clot 
is  called  a  "thrombus."  The  same  process  of  infarction  follows  as 
in  embolism,  (q.  v.) 

Etiology.  The  coagulability  of  the  blood  is  increased  in  preg- 
nancy, in  most  fevers,  after  hemorrhage,  and  in  certain  of  the 
blood  diseases  and  in  cachexia.  In  the  arteries,  where  the  current 
is  usually  comparatively  rapid,  thrombosis  usually  occurs  as  the 
result  of  atheroma,  aneurysm  or  traumatism.  All  of  these  fac- 
tors are  exaggerated  by  the  presence  of  increased  coagulability  of 
the  blood.  Thrombosis  of  veins  may  be  due  to  varicosities,  dis- 
eased vessel  walls,  trauma,  but  is  more  frequently  due  to  those  dis- 
eases which  increase  the  coagulability  of  the  blood.  Marantic 
thrombosis,  in  children  with  marasmus;  cachectic  thrombosis,  in 
patients  with  tuberculosis,  carcinoma  or  chlorosis;  and  anemic 
thrombosis,  after  hemorrhages,  or  in  blood  diseases,  are  not  very 
uncommon  causes  of  apoplectic  attacks.  The  venous  sinuses  in 
the  brain  are  so  broad,  and  so  irregular  in  shape,  the  blood  flows 
more  slowly  through  them  and  thus  coagulation  occurs  more  fre- 
quently in  them  than  in  other  veins.  The  most  common  seat  is 
the  superior  longitudinal  sinus.  When  the  coagulation  is  due  to 
trauma,  the  location  of  the  injury  is  that  of  the  thrombus. 

Diagnosis.  The  onset  is  usually  less  sudden  in  thrombosis 
than  in  embolism  or  hemorrhage.  In  either  the  motor  cortex  may 
be  irritated  and  convulsions  occur;  this  is  rare  in  cerebral  hem- 
orrhage in  adults ;  otherwise  the  symptoms  are  very  much  like 
those  of  hemorrhage. 

Prognosis.  Death  is  less  probable  in  thrombosis  and  embolism 
than  in  hemorrhage.  Absorption  of  the  clot ;  digestion  of  the 
embolus,  within  a  few  days,  may  permit  almost  or  quite  complete 
recovery.  Softening  of  the  brain  may  extend  beyond  the  original 
infarct,  however,  involving  small  vessels;  this  is  especially  true 


378  THE  BRAIN 

in  infected  emboli ;  these  effects,  however,  are  generally  less  serious 
than  are  the  results  of  the  organization  of  the  clot,  or  the  dangers 
of  later  attacks,  in  hemorrhagic  apoplexy. 

Treatment.  When  any  person  is  unconscious,  or  presents  evi- 
dence of  clouded  consciousness,  if  the  limbs  fall  flappily  when 
raised,  especially  if  the  head  and  eye-balls  are  drawn  to  one  side, 
it  is  wisest  to  treat  the  case  as  one  of  apoplexy.  A  smell  of  liquor, 
or  signs  of  chronic  alcoholism,  are  perfectly  in  harmony  with  this 
diagnosis,  and  too  many  unfortunate  men  have  been  allowed  to  die 
from  apoplexy  and  other  diseases  with  coma,  because  they  were 
treated  as  common  drunkards.  It  is  a  disgraceful  fact  that  it  is 
often  considered  a  joke  to  give  a  drunk  man  care,  under  a  mistaken 
diagnosis  of  apoplexy,  while  death  from  the  lack  of  care,  in  apo- 
plexy is  merely  concealed  by  those  responsible  for  the  death. 

The  patient  should  be  kept  recumbent  and  quiet ;  preferably  on 
the  side,  so  that  the  paralyzed  tongue  may  not  interfere  with 
respiration.  The  clothing  must  be  loosened,  if  there  is  any  con- 
striction, especially  at  the  neck  or  the  waist.  Ice  bags  to  the 
head  and  hot  applications  to  the  feet  facilitate  cerebral  drainage. 
Steady,  deep  pressure  in  the  region  of  the  sixth  to  the  tenth 
thoracic  spines,  dilates  the  splanchnic  vessels,  and  withdraws  the 
blood 'from  the  brain;  this  should  lower  the  blood  pressure  and 
cause  diminished  redness  in  the  face.  The  patient  should  not  be 
moved  until  the  breathing  and  the  pulse  become  fairly  regular,  if 
this  is  possible. 

After  the  coma  has  passed,  general  treatment,  such  as  main- 
tains a  good  circulation  of  the  blood,  should  be  given,  at  first  daily, 
later  at  longer  intervals,  to  once  each  week,  until  no  further 
improvement  is  to  be  found.  The  food  must  be  mild,  preferably 
liquid,  and  mostly  of  fruit  and  vegetables  for  some  weeks.  Stim- 
ulating foods  and  drinks  are  forbidden.  Rest  in  bed  is  necessary 
for  several  days,  in  the  light  cases,  and  several  weeks,  in  more 
serious  forms. 

When  the  extent  of  the  paralysis  is  manifest,  and  no  further 
feverishness  or  indications  of  impending  hemorrhage  are  found, 
reeducation  of, the  patient  must  be  begun.  This  reeducation  is 
important.  The  opposite  side  of  the  brain  seems  to  have  a  cer- 
tain amount  of  power  to  control  the  paralyzed  side,  especially  in 
the  more  complicated  movements,  such  as  speech  or  writing. 
Exercises  should  be  carefully  worked  out  for  each  individual,  begin- 
ning with  movements  which  he  is  barely  able  to  begin  even  in  an 
incoordinated  way,  and  goirfg  on  through  increasing  degrees  to 
the  attainment  of  the  greatest  possible  skill.  Dr.  Evelyn  Bush  and 
Dr.  A.  A.  Gour  have  published  articles  giving  such  exercises  in 
greater  detail  than  is  possible  here;  the  underlying  principles  are 
included  in  what  has  been  said — the  adaptation  of  the  exercises  to 


SBNILB  DBMBNTIA  379 

each  individual,  and  a  constant  working  up  to  the  more  difficult 
exercises;  the  first  must  be  very  easy  and  simple. 

DELIRIUM  ACUTUM 

This  is  an  acute,  probably  infectious,  disease  of  the  brain,  occurring  in 
persons  previously  normal  and  not  necessarily  either  neurotic  or  subject  to  any 
hereditary  taint.  The  disease  comes  on  suddenly,  with  a  high  fever,  delirium  is 
very  severe  and  violent.  Lucid  intervals  of  a  few  seconds  to  half  an  hour 
in  duration  may  occur  at  almost  any  time.  The  delirium  recurs  suddenly  after 
these  intervals  and  often  the  fever  is  considerably  higher.  After  death  the 
brain  is  found  full  of  blood  and  showing  the  evidences  of  very_ acute  inflamma- 
tory changes.  The  infectious  agent  has  not  been  isolated.  No  evidence  of  its 
being  contagious  has  been  reported.  The  only  treatment  is  symptomatic.  Ice 
bags  to  the  head  and  cool  sponges  sometimes  seem  to  give  some  relief. 

Death  usually  occurs  within  one  or  two  weeks.  The  few  patients  who 
recover  have  very  slow  convalescence,  but  usually  no  serious  mental  after  effects. 


SENILE  DEMENTIA 

Just  how  long  people  ought  to  live  and  how  long  they  should 
be  expected  to  retain  full  possession  of  the  mental  faculties,  is  a 
question  which  cannot  be  answered.  There  is  very  good  authority 
for  supposing  that  "the  years  of  a  man's  life  shall  be  120,"  but 
this  is  not  at  present  the  case.  The  senile  changes  in  the  tissues 
of  the  body  are  inevitable.  Premature  senility  is-  due  to  overwork, 
especially  to  severe  muscular  exertion  associated  with  exposure 
to  climatic  changes;  to  the  vascular  diseases  associated  with  alco- 
hol, syphilis,  sexual  excesses,  and  overeating;  and  to  inheritance. 

The  brain,  as  a  whole,  undergoes  a  slight  atrophy.  The  sulci 
appear  broader,  the  convolutions  somewhat  smaller;  increase  in  the 
dural  fluid  occasionally  is  found.  Upon  microscopic  examination, 
the  nerve  cells  are  found  atrophied;  the  nuclei  may  be  eccentric, 
and  very  large  masses  of  yellow  pigment  granules  occur  within 
the  nerve  cells.  The  large  multipolar  cells  of  the  cerebral  cortex 
and  Purkinje  cells  of  the  cerebellum  show  atrophy. 

Senility  may  be  considered  premature  in  all  cases  when  it 
occurs  before  the  age  of  sixty.  In  families  in  whom  senility  is 
usually  delayed  until  eighty  or  ninety,  this  process  should  be  con- 
sidered premature  in  any  one  person  at  the  age  of  seventy.  In 
other  words,  the  hereditary  character  of  any  individual  must  be 
taken  into  consideration  in  making  a  diagnosis  of  premature 
senility. 

The  body  may  not  show  senile  changes  even  when  the  mind  is 
seriously  affected ;  on  the  other  hand,  the  body  may  show  all  of 
the  symptoms  of  old  age  to  a  marked  extent  and  yet  the  mentality 
be  apparently  uninjured. 

Treatment.  The  prophylaxis  of  senile  dementia  depends  upon 
the  maintenance  of  a  normal  blood  pressure  and  the  rapid  elimina- 


380  THE  BRAIN 

tion  of  the  toxins  of  the  body  throughout  life.  The  mental  aspect 
is  usually  important.  The  man  or  woman  who  maintains  an 
interest  in  the  world's  progress,  who  takes  up  new  lines  of  thought 
occasionally,  who  is  associated  on  terms  of  friendliness  with  young 
people,  and  who  lives  a  wholesome,  sane  life,  is  less  likely  to  suffer 
from  premature  senility. 

After  the  symptoms  are  observed,  a  great  deal  of  help  can  be 
given  by  properly  planned  treatment  and  attention  to  hygiene. 
People  with  senile  dementia  almost  invariably  have  very  rigid 
spinal  columns  and  ribs;  they  breathe  inefficiently  and  they  have 
either  a  very  high  blood  pressure  or  other  evidences  of  arterio- 
sclerosis with  cardiac  lesions.  The  treatment  must  be  based 
upon  as  much  of  a  relief  from  these  conditions  as  is  possible. 
Treatments  which  very  gently  increase  the  mobility  of  the  ver- 
tebrae and  which  raise  the  ribs,  increasing  the  flexibility  of  the 
thorax,  often  cause  very  satisfactory  improvement  in  the  symp- 
toms. If  possible,  the  patient  should  be  taught  better  habits  of 
breathing  and  should  be  made  to  take  an  interest  in  something  out- 
side of  his  recent  experiences.  If  he  has  been  taking  alcohol  and 
tobacco,  it. is  probably  unwise  to  deprive  him  of  these  things 
altogether,  though  in  most  cases  a  reduction  is  advisable.  The 
diet  should  be  light  and  easily  digested.  Milk  and  buttermilk, 
fresh  green  vegetables  and  fruits  should  make  up  by  far  the  larger 
proportion  of  his  food.  He  needs  little  or  no  meat  and  only  a  very 
small  amount  of  starchy  food.  An  increased  amount  of  water 
should  be  taken.  If  he  can  be  induced  to  drink  as  much  as  his 
heart  and  kidneys  will  permit,  the  increased  elimination  of  toxins 
will  be  promoted  most  satisfactorily. 

Prognosis.  Naturally,  no  hope  of  recovery  is  possible,  but 
considerable  relief  from  the  symptoms  in  early  senile  dementia 
may  be  expected.  Attacks  of  paralysis  and  occasionally  epilepti- 
form attacks  may  occur  and  either  of  these  or  some  intercurrent 
malady,  especially  pneumonia,  provide  the  last  injury  necessary 
to  death. 

HYDROCEPHALUS 

This  term  is  applied  to  any  condition  in  which  the  amount  of 
cerebrospinal  fluid  within  the  skull  is  greatly  increased.  It  may 
be  either  congenital  or  acquired,  or  may  be  either  internal  or 
external. 

Congenital  Hydrocephalus  may  occur  without  recognizable 
cause.  Its  more  frequent  occurrence  in  the  children  of  alcoholic 
parents  suggests  the  "wet  brain"  of  alcoholism  (see  serous  men- 
ingitis). Prenatal  infection  of  the  meninges  and  chronic  ependy- 
mitis,  due  to  any  one  of  several  infectious  and  toxic  agencies,  is 
tobe  recognized.     Congenital  hydrocephalus  is  more  frequently 


HYDROCEPHALUS  381 

internal.  The  head  may  be  tremendously  enlarged;  the  fontanels 
remain  open,  or  are  closed  by  Wormian  bones;  the  sutures  spread 
widely  apart,  and  Wormian  bones  may  be  interposed.  The  cere- 
bral cortex  is  thinned,  sometimes  until  it  contains  little  or  no 
recognizable  gray  matter;  the  white  matter  may  be  scarcely  per- 
ceptible. The  basal  ganglia  are  flattened;  the  lateral  and  third 
ventricles,  and  the  cerebral  aqueduct  (of  Sylvius)  are  greatly 
dilated ;  the  fourth  and  fifth  ventricles  are  rarely  dilated.  The 
cerebellum  may  or  may  not  be  flattened  greatly.  Children  in 
whom  very  slight  hydrocephalus  is  present  may  attain  normal  or 
remarkable  mentality;  those  in  whom  the  hydrocephalus  is  suffi- 
cient to  cause  noticeable  deformity  of  the  skull,  with  injury  to 
the  brain,  are  mentally  defective,  and  suffer  from  spastic  paralysis, 
epileptic  attacks,  and  malnutrition.  The  skull  is  rounded,  rather 
than  square,  as  in  rickets,  and  the  malnutrition  of  the  body  is 
not  associated  with  bony  fragility.  Congenital  hydrocephalus  is 
frequently  associated  with  spina  bifida  and  with  club  foot,  various 
slight  bodily  deformities,  and  stigmata  of  degeneracy  of  varying 
types. 

Congenital  external  hydrocephalus  is  usually  due  to  deformity 
of  the  brain,  with  normal  skull  size,  or  to  abnormally  large  skull 
with  normal  brain.  In  the  latter  case  previously  existing  internal 
hydrocephalus  is  suspected. 

Acquired  external  hydrocephalus  may  appear  at  any  time  of 
life,  but  is  most  frequent  during  the  first  few  months,  or  in  senility. 
Wasting  of  the  brain  may  leave  a  space,  which  is  filled  with  liquid 
(vacuum  dropsy),  or  there  may  be  an  increased  secretion,  probably 
inflammatory,  of  the  endothelial  cells. 

Acquired  internal  hydrocephalus  is  due  to  meningitis  or  to 
brain  tumor.  Closure  of  the  veins  of  Galen  or  of  the  foramina  of 
Monro  or  of  Majendie  result  in  an  acccumulation  of  fluid  within 
the  ventricles.  Softening  of  the  brain,  epileptic  attacks,  various 
paralyses,  and  coma  lead  to  death. 

Diagnosis.  The  disease  is  suspected  when  enlargement  of  the 
head  in  children,  or  symptoms  of  increased  intracranial  pressure 
in  adults,  are  associated  with  any  of  the  etiological  factors.  Exam- 
ination of  the  cerebrospinal  fluid,  and  the  use  of  the  X-ray,  par- 
ticularly of  the  stereoscopic  views  of  the  skull,  should  make  the 
diagnosis  clear  in  most  cases. 

Treatment.  Drainage  of  the  fluid  from  lumbar  puncture  gives 
relief  and  may  lead  to  recovery ;  pressure  upon  the  skull,  by 
straps  and  bandages,  may  lead  to  absorption  of  the  fluid,  and  pre- 
vent its  greater  formation.  Drainage  of  the  cisterna,  directly,  is 
of  doubtful  value  and  of  certain  danger.  Palliative  measures 
include  correction  of  cervical  and  upper  thoracic  lesions,  and  atten- 
tion to  the  nutrition  of  the  entire  body.    Children  with  heavy  heads 


382  THB  BRAIN 

should  not  be  encouraged  to  try  to  hold  the  head  up,  but  some 
support  should  always  be  given;  the  heavy  head  swinging  around 
on  the  weak  neck  leads  to  various  cervical  and  upper  thoracic 
lesions,  which  still  further  embarrass  the  circulation  and  drainage 
of  the  cranial  cavity. 

AMAUROTIC  FAMILY  IDIOCY 

Amaurotic  family  idiocy  is  a  hereditary  degenerative  disease  of  the  brain, 
characterized  by  progressive  blindness  and  loss  of  mentality.  Direct  inheritance 
is,  of  course,  impossible,  but  the  disease  attacks  several  members  of  the  family 
in  each  generation.  Normal  children  may  be  found  in  the  same  family,  but 
all  the  children  in  one  family  who  suffer  from  this  disease  show  the  first 
symptoms  at  about  the  same  time. 

Two  types  of  this  disease  are  recognized.  One  attacks  infants  and  results  in 
complete  idiocy  and  death  before  the  age  of  three  years;  in  the  other  the  onset 
is  somewhat  later,  perhaps  at  about  the  fifth  year,  and  death  may  be  postponed 
until  the  tenth  year,  or  rarely  later. 

The  brain  shows  no  changes  on  macroscopic  examination  as  a  rule,  though 
sometimes  irregularities  in  the  convolutions  occur.  On  microscopic  examination 
degenerative  processes  in  the  cerebral  neurons  are  observed.  Swellings  of  the 
cell  bodies  are  especially  conspicuous.  The  granular  layer  of  the  retina  shows 
the  same  changes;  atrophy  is  usually  present  in  retina  and  optic  nerves. 

The  disease  is  limited  almost  exclusively  to  children  of  Jewish  descent.  One 
very  typical  case  in  the  P.  C.  O.  clinic  had  no  history  of  Jewish  ancestry. 

No  treatment  is  of  real  value.  The  case  is  hopeless  from  the  beginning  and 
the  most  that  can  be  done  is  to  keep  the  child  comfortable  for 'the  remaining 
months  of  his  life. 

CEREBRAL  PARALYSES  OF  CHILDREN 

The  paralyses  which  appear  first  in  childhood  are  characterized 
by  a  number  of  factors  which  are  not  present,  or  are  present  in 
different  degree,  ir.  the  paralyses  which  first  appear  during  adult 
life,  or  in  old  age.  The  etiology  of  .children's  paralyses  is  greatly 
different  from  that  of  adult  paralysis,  though  both  are  based  upon 
destruction  of  nerve  cells. 

Etiology.  Paralysis  in  children  may  be  due  to  any  one  of  a 
large  number  of  factors.  Specific  infection,  as  in  anterior  polio- 
myelitis, or  the  infectious  agents  present  in  most  of  the  acute 
infectious  diseases  of  childhood,  may  destroy  the  nerve  centers  in 
the  cord  or  the  brain.  Trauma,  after  birth,  at  birth,  or  before 
birth,  may  injure  the  peripheral  nerves,  as  in  paralysis  of  the 
brachial  plexus  produced  by  pressure  upon  the  shoulder  in  deliv- 
ery. Long  labor  or  awkwardly  used  forceps  may  injure  the 
brain  directly ;  long  labor  or  asphyxia  may  lead  to  cerebral  or 
meningeal  hemorrhage.  Jaundice  may  poison  the  nerve  cells; 
marasmus  may  prevent  brain  development ;  the  acute  fevers  may 
injure  by  overheat  or  by  bacterial  poisons.  Premature  birth 
may  be  associated  with  malnutrition,  or  the  causes  of  the 
prematurity  may  aflfect  the  brain  development.     Before  birth,  the 


PARALYSIS  OF  CHILDREN  383 

nutrition  may  be  hTelow  normal ;  maternal  toxins  may  injure ; 
direct  trauma  to  the  fetus  through  the  mother's  abdomen,  is  not 
rare ;  attempts  at  abortion  may  injure  the  fetal  head  and  brain. 
(See  Hemorrhage  into  Fetal  Cord,  C.  A.  Whiting.)  Deformities 
of  the  nervous  system  cannot  always  be  explained ;  these  result  in 
variable  disturbances  of  function,  often  including  more  or  less 
paralysis.  Heredity  is  important.  Syphilis  in  the  parents  stands 
first;  next  alcoholism  is  to  be  considered;  neurotic  inheritance, 
especially  familial  defects  of  body  or  mind,  is  frequently  found ; 
these  hereditary  qualities  follow  the  laws  of  Mendel.  Children  of 
very  old  parents,  and  those  born  last  in  very  large  families,  are 
more  liable  to  nerve  instability  and  paralysis.  Children  of  the 
cachectic,  those  born  during  serious  ill-health  of  the  parents,  are 
rather  often  paralytic. 

Yet,  after  all,  in  very  many  cases,  no  efficient  cause  for  the 
paralysis  can  be  found,  even  upon  the  most  thorough  and  careful 
investigation. 

Pathology.  Examination  of  the  brains  of  such  children  shows  vari- 
ous defects.  Usually  the  cerebral  and  spinal  injury  is  much  more  serious  than 
would  be  expected  from  the  symptoms  observed.  This  is,  no  doubt,  due  to 
the  fact  that  in  childhood  a  great  deal  of  compensatory  action  on  the  part  of 
other  developing  nerve  centers  is  possible. 

Meningeal  hemorrhage  at  birth  is  frequent;  this  may  cause  no  recognizable 
symptoms  in  a  large  majority  of  cases.  Large  hemorrhages  clot,  are  digested 
and  ultimately  are  absorbed ;  or  they  become  organized  with  scar-like  formation 
of  connective  tissue  and  neuroglia;  or  these  form  a  wall,  within  which  the 
digested  blood  and  nerve  matter  undergo  further  softening  until  a  cyst  filled 
with  a  clear  and  colorless  liquid  remains.  These  "hemorrhagic  cysts"  are 
often  found  in  the  brains  of  defective  children.  Thrombosis  is  not  rare  at 
about  the  time  of  birth;  this  causes  infarction,  perhaps  softening,  perhaps  cyst 
formation. 

Mal-development  is  indicated  by  variations  in  the  size  and  form  of  the 
convolutions,  by  imperfect  myelinization  of  tracts,  especially  the  pyramidal 
tracts,  and  by  the  presence  of  atypical  patches  of  gray  matter  scattered  through 
the  white  matter,  especially  in  the  subcortical  region.  Various  atypical  relations 
and  defects  of  the  circulation  are  found. 

The  effects  of  hydrocephalus  may  also  be  found,  in  many  cases  (q.  v.). 
Hereditary  syphilis  is  indicated  more  vividly  in  the  viscera  and  skin  than  in  the 
brain  itself;  syphilitic  lesions  of  the  brain  resemble  the  circulatory  defects 
already  mentioned. 

Defects  in  the  brain  substance  are  frequent;  these  may  be  due  to  pressure 
of  cysts,  hemorrhages,  etc.,  which  may  have  been  absorbed , before  death;  or  to 
hydrocephalus ;  or  to  abiotrophic  changes ;  or  to  deformities  of  unknown  cause. 

Sclerosis  due  to  neurogliar  overgrowth  is  not  uncommon.  This  may  be 
diffuse  or  patchy,  or  may  occur  in  hard,  raised,  knob-like  elevations. 


CEREBRAL  HEMIPLEGIA  OF  CHILDREN 

This  disease  is  due  to  destruction  of  the  nerve  cells  and  fibers 
of  the  cerebrum,  appears  early  in  life,  and  causes  paralysis  of  arm 
and  leg,  rarely  face,  upon  the  opposite  side. 


384  THE  BRAIN 

Etiology.  The  disease  usually  has  its  onset  in  the  first  three 
years  of  life;  occasionally  appears  to  be  due  to  birth  injury;  and 
often  follows  an  acute  infectious  disease,  or  a  series  of  children's 
acute  infections.  Occasionally  it  seems  to  be  primary.  The  onset 
and  later  history  suggest  infection,  as  in  infantile  paralysis,  but 
no  infectious  agent  has  yet  been  isolated. 

Diagnosis.  The  child  shows  no  prodromal  symptoms,  save 
those  of  the  contagious  disease,  when  this  is  present;  has  high 
fever,  vomiting,  convulsions,  and  some  torpor.  As  this  passes 
away,  one  side  of  the  body  and  face  are  found  to  be  paralyzed  first 
with  relaxed  muscles,  which  soon  become  spastic.  Aphasia  is 
usually  present,  no  matter  which  side  of  the  body  is  paralyzed,  if 
the  child  has  begun  to  talk.  Within  a  few  days,  the  aphasia 
passes,  and  the  paralysis  lessens.  Recovery  is  not  complete,  and 
the  arm  is  most  seriously  affected.  Within  a  few  weeks  the  extent 
of  paralysis  is  fixed.  The  muscles  which  recover  motor  power 
show  athetoid  movements  and  spasmodic  twitchings.  Within  a 
year  or  two,  attacks  of  epilepsy  occur;  these  are  mild  at  first  but 
increase  in  severity.  With  these,  mental  deterioration  becomes 
evident,  and  this  may  go  on  to  amentia.  In  some  cases  the  epi- 
lepsy and  mental  deterioration  do  not  occur,  and  the  after  life  of 
the  child  is  affected  only  very  slightly  by  the  paralysis.  The 
growth  of  the  paralyzed  limbs  is  deficient,  as  in  infantile  paralysis. 
In  some  cases  the  extent  of  the  paralysis  is  slight,  but  the  mental 
effects  are  profound — paralysis  of  the  intellect. 

Treatment.  After  the  paralysis  is  evident,  the  treatment  should 
be  directed  first  to  securing  the  best  possible  circulation  of  the  best 
possible  blood  through  the  brain,  cord  and  muscles;  next  to  the 
orthopedic  correction  of  the  deformities  resulting  from  the  paral- 
ysis. Special  training  is  necessary  for  those  children  in  whom 
epilepsy  and  mental  deterioration  are  beginning;  such  children 
should  be  taught  cleanly  habits,  and  as  much  of  good  humor  as  is 
possible;  but  education,  in  the  sense  of  "book  learning,"  is  mostly 
thrown  away.  Too  urgent  efforts  toward  teaching  hasten  the 
ultimate  amentia.  Sane,  wholesome  living,  with  such  work  as  they 
can  do  cheerfully  and  easily,  provide  the  education  that  is  best  for 
them. 

Prognosis.  The  outlook  is  bad.  For  two  or  three  years  after 
the  paralysis,  the  imminence  of  epilepsy  must  be  recognized.  The 
greater  the  athetoid  movements  the  greater  the  danger  of  mental 
defect.  Early  cessation  of  athetoid  or  choreic  movements  is  a 
good  sign.  When  the  epileptic  attacks  are  frequent  the  prognosis 
is  worse  than  when  they  occur  at  longer  intervals,  even  though 
the  less  frequent  attacks  may  be  more  severe.  Mental  deteriora- 
tion is  practically  certain  when  epilepsy  follows  hemiplegia  in 
children. 


DIPLEGIA  385 

Life  is  rarely  interrupted  or  shortened.  After  the  climacteric 
the  epileptic  attacks  may  disappear ;  mentality  is  not  usually  modi- 
fied by  this. 

DOUBLE  HEMIPLEGIA 

Occasionally  this  disease  affects  both  sides  of  the  body,  and  a  condition 
resembling  cerebral  diplegia  results.  In  double  hemiplegia  the  onset  is  like  that 
of  cerebral  hemiplegia,  athetoid  movements,  epileptic  attacks,  etc.,  all  resemble 
those  of  the  unilateral  type,  and  the  mental  deterioration  is  marked.  In  some 
cases,  however,  it  may  be  quite  impossible  to  distinguish  between  the  paralysis 
due  to  disease  (hemiplegia)  and  the  paralysis  due  to  defective  development 
(Little's  disease). 

CHOREIC  HEMI-PARESIS 

This  disease  is  probably  related  to  cerebral  hemiplegia.  The  paralytic 
stage  is  omitted,  and  choreic  and  athetoid  movements  of  one  half  the  body 
occur,  as  in  the  post-hemiplegic  stage  of  the  disease  mentioned.  The  onset  is 
more  insidious,  and  it  usually  follows  either  severe  acute  infectious  disease,  or  a 
very  severe  fright  or  nervous  shock. 

CEREBRAL  DIPLEGIA 

(Little's  disease) 

Cerebral  diplegia  is  a  paralysis  due  to  defective  development 
of  the  pyramidal  tracts ;  it  affects  the  legs  more  seriously  than  the 
arms,  as  a  rule;  and  is  especially  characterized  by  rigidity  of  the 
skeletal  musc*les.  Sometimes  paraplegia  alone  is  present,  with 
characteristics  of  Little's  disease. 

Etiology.  The  disease  is  due  to  defective  development;  this, 
in  turn,  to  asphyxia  at  birth,  difficult  labor,  or  to  deficient  nutrition 
before  birth.  Premature  birth  is  mentioned;  this  may  be  the  cause 
of  the  disease,  or  both  disease  and  premature  birth  may  be  due  to 
some  earlier  defect  in  development.  Upper  cervical  lesions  seem 
to  be  constant  findings.  These  may  often  be  secondary,  and  often 
appear  to  have  been  caused  at  birth.  In  any  case,  they  usually 
seem  to  be  important  in  the  later  history  of  the  patient. 

The  pyramidal  tracts,  and  sometimes  the  motor  cortex,  are 
found  undeveloped ;  the  tracts  are  nonmedullated  or  may  be  absent. 
This  defect  leaves  the  reflex  arcs  of  the  spinal  cord  uncontrolled; 
whence  the  rigidity. 

Diagnosis.  The  entire  motor  system  in  its  lower  mechanism 
seems  to  be  irritable;  these  children  are  thrown  into  spasms  by 
sudden  noises  or  lights.  The  mothers  notice  these  spasmodic 
movements,  and  think  the  child  is  "trying  so  hard  to  understand, 
and  to  learn  to  control  himself."  Refle:5^es  are  increased ;  in  some 
cases  it  is  difficult  to  recognize  the  reflex  response  on  account  of 
the  rigidity.  It  may  be  noticed  that  the  child  is  too  stiflf,  even 
when  it  is  very  small ;  when  it  should  be  holding  up  the  head,  this 
is  not  done ;  when  it  is  time  for  it  to  sit  alone,  it  is  noticed  that  the 


386  THE  BRAIN 

legs  do  not  bend  properly,  and  that  the  child  stiffens  iself  out, 
instead  of  making  the  usual  movements  of  the  legs  and  arms. 
Sometimes  the  condition  \s  not  noticed  until  the  child  should  begin 
to  learn  to  walk.  The  rigidity  of  the  legs  causes  them  to  be  drawn 
together,  so  that  they  may  cross;  if  the  child  is  helped  and  the  legs 
moved  as  in  walking,  or,  in  lighter  cases,  if  he  learns  to  walk,  the 
legs  cross,  "scissors  gait,"  and  the  walking  movements  are  ex- 
tremely stiff  and  slow.  The  muscles  may  be  smaller  than  normal, 
or  may  hypertrophy;  there  is  never  any  true  atrophy,  as  in  other 
types  of  children's  paralysis. 

The  development  of  the  tracts  may  simpl)'-  be  delayed,  in  which 
case  the  symptoms  gradually  disappear,  and  the  child  appears 
fairly  normal  at  ten  or  twelve  years  of  age.  In  most  cases,  how- 
ever, the  development  never  reaches  the  normal,  and  he  is  more 
or  less  crippled  during  life. 

Mental  development  is  defective,  if  the  paralysis  is  marked ;  in 
this  disease  the  defect  in  mentality  seems  to  run  a  fairly  parallel 
course  with  the  paralysis.  The  vocal  muscles  are  often  affected, 
and  this  mutism  increases  the  tendency  to  mental  defect.  When 
the  face  is  not  involved,  the  children  are  often  quite  intelligent  in 
appearance,  with  friendly  smiles  and  expressions  such  as  normal 
children  have  under  different  circumstances  of  joy  or  grief. 

Treatment.  In  order  that  every  possible  opportunity  may  be 
given  the  developmental  powers  of  the  nervous  system,  the  con- 
stant care  of  the  nurse  and  the  physician  is  necessary.  Treat- 
ment must  be  adapted  to  conditions  as  they  arise ;  very  important 
is  the  repeated  correction  of  the  bony  lesions  which  are  caused 
by  the  muscular  tension.  Once  or  twice  each  week  the  body 
must  be  examined,  and  very  gentle  manipulations  given,  which 
increase  the  mobility  of  the  spinal  column  and  the  ribs.  If  these 
increase  the  rigidity,  there  is  some  error  in  technique;  the  result 
of  each  treatment  should  be  to  slightly  diminish  the  muscular 
tension.  Daily  massage  of  the  affected  muscles,  if  gently  done, 
is  good;  this  gives  the  exercise  in  as  nearly  normal  a  way  as 
is  possible.  Prolonged  warm  baths  often  relieve  the  rigidity ;  mas- 
sage during  the  bath  is  especially  useful. 

Education  should  be  wisely  attempted.  The  child  should  be 
taught  to  rest,  first;  later  very  simple  and  easy  movements  should 
be  given.  At  first  only  those  movements  which  he  can  make  easily 
should  be  given ;  later,  these  may  be  increased.  It  must  be  remem- 
bered that  the  brain  centers  are  undeveloped,  and  that  very  little 
overuse  may  result  in  harmful  tiring;  constant  watchfulness  is 
necessary.  The  results  which  have  been  secured  in  a  few  cases 
as  the  result  of  this  persistent  treatment  by  osteopathic  physicians, 
with  the  assistance  of  good  nursing,  is  most  encouraging. 


BRAIN  TUMOR  387 

Prognosis.  The  outlook  is  always  grave,  but  in  all  cases  of 
typical  Little's  disease  there  is  a  chance  for  the  later  development 
of  the  defective  tracts.  .  •  . 

LENTICULAR  DISEASE 

Disease  of  the  corpora  striata,  and  especially  of  the  lenticular  nucleus,  has 
been  describee!  by  several  authors.  The  progressive  softening  associated  with 
cirrhosis  of  the  liver  is  of  interest.  The  symptoms  of  lenticular  disease  include 
tremor,  often  intentional;  spasticity  of  the  skeletal  muscles,  usually  bilateral 
and  universal;  excessivie  emotionahsm;  dysphagia;  dysarthria  but  no  true 
aphasia;  difficulty  in  maintaining  equilibrium  but  no  true,  ataxia;  and  usually 
no  reflex  disturbances  or  sensory  peculiarities.  Athetoid  movements  and  spas- 
modic actions  may  occur. 

When  associated  with  cirrhosis  of  the  liver,  recovery  is  not  to  be  expected 
Similar  cases  due  to  the  presence  of  some  pecuHar  toxin,  which  can  be  eliminated 
from  the  blood,  may  disappear  with  treatment. 

Rarely,  Babinski's  sign,  increased  reflexes,  and  mental  deterioration  are 
present;  these  cases  are  not  expected  to  recover. 

BRAIN  TUMOR 

The  term  "brain  tumor"  is  applied  to  any  neoplasm  or  deposit 
of  any  kind  which  aflfects  the  brain  in  any  way,  either  directly  or 
by  causing  increased  intracranial  pressure.  It  is  not  usually  pos- 
sible to  diagnose  the  variety  of  tumor  until  after  death  or  operation. 

Varieties.  Tumors  may  originate  from  the  membranes,  the 
blood  vessels,  the  neuroglia,  or  the  connective  tissues.  They  may 
originate  in  place,  or  as  metastases. 

Membranous  tumors  include  enchondroma  or  osteoma,  from 
the  dura  or  the  skull;  psammona,  usually  from  the  neighborhood 
of  the  pineal  body ;  lipoma,  cholesteatoma,  fibroma,  myxoma,  sar- 
coma, endothelioma,  angioma,  from  the  dura  and  the  pia-arachnoid ; 
carcinoma,  practically  always  metastatic;  tubercle  and  gumma,  re- 
sulting from  infections. 

From  the  blood  vessels  arise  aneurysms,  tubercles,  gummata, 
and  angiomas,  perhaps  also  endotheliomas.  From  the-  neuroglia 
arise  gliomas.  From  the  connective  tissue  grow  fibroids  and  sar- 
comatous growths. 

Tumors  of  extraneous  origin  include  hydatids,  rare  in  this 
country ;  cysterci ;  and  many  even  more  rare  varieties.  Brain  cysts 
are  usually  caused  by  destruction  and  digestion  of  brain  tissue 
or  of  extravasated  blood.  Hematoma  is  due  to  hemorrhage  (See 
apoplexy). 

Etiology.  Tubercle  is  more  common  in  children;  glioma  and 
sarcoma  in  youths;' gumma  in  adults;  carcinoma  in  late  middle 
life ;  and  others  according  to  the  nature  of  the  infectious  cause,  or 
the  nature  of  the  neoplasm,  or  the  opportunity  for  traumatic 
causes.  Men  are  more  frequently  affected  than  women,  probably 
on  account  of  the  incidence  of  gumma  and  the  risk  of  trauma. 


388  THE  BRAIN 

Diagnosis.  The  diagnosis  of  brain  tumor  is  usually  difficult, 
especially  in  the  early  stages,  and  when  it  does  not  affect  the  mem- 
branes. Symptoms  are  due  partly  to  the  increased  intracranial 
pressure,  and  partly  to  the  local  irritation  and  destruction  of 
brain  tissue. 

Headache  is  present  only  when  the  meninges  are  involved; 
since  the  brain  substance  is  devoid  of  sensory  nerves.  Uncom- 
fortable sensations  may  result  from  local  irritation,  however. 
Rarely,  pain  may  be  elicited  on  percussion,  near  the  tumor,  but 
this  is  subject  to  so  many  modifying  influences  that  it  is  not 
satisfactory  as  a  means  of  diagnosis.  Vertigo  is  common;  it  is 
most  marked  in  cerebellar  disease.  Vomiting  is  also  most  frequent 
and  annoying  in  cerebellar  tumor.  It  may  be  of  the  projectile  type, 
or  may  be  of  the  commoner  variety ;  it  bears  no  relation  to  the 
quality  or  the  time  of  meals.  Choked  disk  is  almost  invariable ; 
interlacing  of  the  limits  of  the  color  fields  is  a  frequent  ocular 
finding,  considered  of  great  value  in  more  recent  writings.  Mental 
disturbances  usually  include  dullness  and  apathy ;  rarely  mania. 
Emotional  or  hysteroid  attacks  are  frequent  in  some  cases;  in- 
creased emotional  instability  is  usually  present,  especially  when 
the  frontal  lobe  or  the  basal  ganglia  are  aflfected.  Constitutional 
symptoms  include  emaciation,  adiposity,  peculiarities  of  the  pulse 
and  respiration,  varying  temperatures,  most  marked  in  basal  gan- 
glia disturbances,  and  pupillary  changes. 

The  focal  symptoms  vary  chiefly  according  to  the  fossa  involved. 
Tumors  of  the  anterior  frontal  region  give  only  vague  or  elusive 
symptoms,  chiefly  mental  disturbances  of  orientation  and  behavior. 
Tumors  affecting  the  speech  and  writing  centers,  in  the  second 
and  third  frontal  convolutions,  destroy  these  powers.  Tumors  of  the 
precentral  area  cause  first,  convulsive  movements  and  epileptoid 
attacks,  or  Jacksonian  epilepsy,  later,  paralysis;  in  the  post-central 
convolution,  paresthesias  are  followed  by  anesthesias,  and  these 
may  be  associated  with  convulsive  or  epileptoid  attacks.  Tumors 
of  the  right  anterior  frontal  and  a  large  part  of  the  parietal  and 
temporal  lobes  may  cause  no  localizing  symptoms.  Lesions  of  the 
posterior  area  of  the  parietal  lobe,  especially  on  the  left  side,  cause 
astereognosis ;  of  the  occipital  lobes,  especially  the  angular  gyrus 
and  cuneus,  give  varying  light  flashes  during  the  irritative  stage, 
if  present,  followed  by  homonymous  bilateral  hemianopsia.  Lesions 
of  the  occipito-temporal  region  cause  auditory  and  visual  aphasia. 

When  the  base  of  the  brain  is  affected,  ocular  symptoms  are 
marked ;  this  is  due  to  the  effects  upon  the  optic  and  the  oculo- 
motor nerves.  The  region  of  the  sella  turcica  is  most  often  affected 
of  all  tumors  in  the  supratentorial  region,  and  this  leads  to  blind- 
ness, through  pressure  upon  the  optic  chiasm.  The  pituitary  gland 
is  often  concerned,  with  the  symptoms  of  disease  of  that  ductless 
gland,  (q.  v.)  .  c 


ENCEPHALITIS  389 

Tumors  affecting  the  basal  ganglia  are  often  associated  with 
emotional  instability,  involuntary  laughing  or  crying  attacks, 
athetoid  movements  of  the  limbs,  especially  the  fingers  and  arms, 
and  peculiar  hesitating  speech.  Lesions  of  any  kind  in  the  basal 
ganglia  are  apt  to  involve  the  internal  capsule,  with  resulting 
widespread  paralysis  and  usually  more  or  less  motor  aphasia. 

The  cerebellum  and  cerebello-pontine  angle  are  often  the  seat 
of  tumors.  Subtentorial  tumors  do  not  cause  symptoms  of  in- 
creased intracranial  pressure  unless  the  tumor  is  of  considerable 
size,  or  involves  the  aqueduct,  thus  leading  to  internal  hydro- 
cephalus. The  localizing  symptoms  depend  chiefly  upon  the  effects 
upon  the  cranial  nerves,  unless  the  middle  lobe  of  the  cerebellum 
is  affected.  When  this  occurs,  the  symptoms  progress  rapidly. 
Cerebellar  ataxia  is  marked;  the  Romberg  sign  is  present;  the 
skeletal  muscles,  especially  those  of  the  legs  and  back,  are  weak- 
ened and  may  either  be  atonic  or  hypertonic,  sometimes  variably 
on  the  two  sides ;  nystagmus ;  various  symptoms  of  cranial  nerve 
involvement ;  strabismus ;  intense  headache ;  severe  vertigo,  and 
often  vomiting  without  digestive  disturbance,  are  present. 

Some  part  of  the  auditory  tract  is  usually  affected  in  cerebellar 
or  cerebello-pontine  tumor;  tinnitus  and  deafness,  and  the  symp- 
toms of  Meniere's  disease  are  thus  produced. 

Tumors  of  the  pons,  if  small,  produce  varying  motor  and  sen- 
sory symptoms,  according  to  the  location  and  the  function  of  the 
areas  affected.  Tumors  of  the  peduncles  cause  cerebellar  symptoms. 
Tumors  invading  the  fourth  ventricle,  of  slow  growth,  cause  dia- 
betes insipidus  or  mellitus,  and  sensory  and  motor,  cardiac,  res- 
piratory and  vasomotor  symptoms,  according  to  the  areas  affected. 
Death  is  not  long  delayed  when  the  visceral  symptoms  appear. 

Treatment.  The  most  satisfactory  treatment  in  most  cases  is 
surgical.  Inoperable  cases  are  more  or  less  slow  in  development, 
according  to  the  nature  of  the  case.  Tubercle  and  gumma  are  to 
be-  treated  constitutionally.  Decompression  operations  may  pro- 
long comfortable  existence  for  weeks  or  months;  occasionally 
decompression  permits  later  reparative  surgery.  In  any  case  of 
increased  intracranial  pressure,  measures  which  lower  the  sys- 
temic blood  pressure  may  give  temporary  relief. 

SUPPURATIVE  ENCEPHALITIS 

(Abscess  of  the  brain) 

Etiology.  Direct  injury  is  the  most  frequent  cause;  pyemia 
causes  multiple  small  foci ;  extension  of  infection  from  the  mastoid 
cells,  the  nasal,  and  other  neighboring  areas  is  sometimes  causative; 
rarely  circulatory  disturbances,  due  to  any  of  the  usual  causes,  is 
followed  by  infection  and  abscess.  More  often  such  conditions  are 
followed  by  softening  by  autolytic  enzymes  than  by  infection. 


390  THB  BRAIN 

Diagnosis.  The  symptoms  are  those  of  tumor,  plus  those  of 
suppuration — these  include  chills  and  fever,  leucocytosis,  indicanu- 
ria,  and  often  the  symptoms  of  the  primary  infection,  as  typhoid, 
pneumonia,  or  endocarditis.  Retinal  congestion  is  usually  marked, 
but  choked  disk  is  rare.  The  symptoms  progress  by  extension 
along  the  line  of  least  resistance,  rather  than  by  increasing  inten- 
sity in  one  place,  as  in  tumor.  Multiple  abscesses  often  follow,  as 
in  one  P.  C.  O.  specimen,  in  which  an  unsuspected  temporal  abscess 
underlay  an  old  bullet  cyst,  with  multiple  abscesses  of  micro- 
scopic size  over  the  cerebral  and  cerebellar  cortices ;  the  apparent 
cause  of  death  was  the  rupture  of  the  abscess  into  the  ventricle. 

Treatment.  When  the  abscess  can  be  localized,  the  pus  may 
be  evacuated,  and  recovery  follow.  When  diagnosis  is  doubtful, 
and  the  pus  cannot  be  localized,  systemic  treatment  is  to  be 
employed ;  this  includes  correction  of  the  cervical  and  occipital 
lesions,  promotion  of  nutrition  and  elimination,  liquid  diet,  with 
free  drinking  of  water;  palliative  treatment  for  the  symptoms  as 
they  appear,  and  constant  watchfulness  in  order  that  surgical  inter-* 
ference  may  be  based  upon  as  exact  knowledge  as  possible. 

Prognosis.  When  evacuation  of  the  pus  is  not  surgically  se- 
cured, the  abscess  may  break  into  the  nasal  passage,  with  imme- 
diate relief  and  recovery ;  into  a  venous  sinus,  with  septicemia  and 
ultimately  death,  or  into  a  cerebral  ventricle,  with  sudden  death. 
In  all  cases  the  prognosis  for  life  is  serious,  and  recovery  is  apt  to 
be  slow  and.  incomplete,  in  the  most  favorable  circumstances.    ' 


CHAPTER  XXXVII 
FUNCTIONAL  NEUROSES 

HYSTERIA 

Hysteria  is  a  functional  disease  of  the  nervous  system,  charac- 
terized chiefly  by  various  .constant  disturbances  of  sensation  and 
motion  and  by  occasional  exacerbations  of  these  disturbances  or 
by  convulsive  attacks. 

Pathogenesis.  No  morbid  anatomy  has  been  described  for  hysteria, 
though  several  investigators  have  reported  finding  aberrant  masses  of  gray 
matter  and  various  slight  irregularities  in  the  form  of  the  cerebral  convolu- 
tions. It  is  difficult  to  understand  how  any  single  disease-producing  factor  can 
possibly  be  responsible  for  phenomena  so  varied  and  apparently  so  antagonistic 
as  are  the  symptoms  of  hysteria.  The  most  satisfactory  theory  depends  upon 
a  recognition  of  the  nature  of  the  inhibitions  under  normal  conditions.  Minimal 
stimuli  repeated  at  intervals  too  great  to  produce  summation  may  so  affect  the 
nerve  centers  as  to  prolong  the  refractory  periods  into  a  constant  inhibitory 
effect.  In  hysteria  the  liminal  value  of  the  nerve  centers  is  so  greatly  increased 
that  stimuli  which  ordinarily  are  inhibitory  are  now  of  no  effect  whatever, 
while  stimuli  which  should  ordinarily  produce  marked  effects  in  consciousness  or 
in  bodily  activity  are  now  reduced  to  a  level  of  inhibitory  reactions.  The 
specific  symptoms  in  each  case  depend  upon  the  location  of  the  nerve  centers 
affected ;  this,  in  turn,  depends  upon  the  etiological  factors  present  in  each  case, 
and  upon  the  physiological  condition  of  the  different  centers  at  the  time  of 
irritation. 

Etiology.  By  far  the  most  important  cause  of  hysteria  lies  in 
heredity.  Hysteria  is  one  of  a  group  of  neuroses  which  are  inter- 
changeable in  inheritance;  that  is,  if  one  parent  has  migraine  and 
another  is  addicted  to  the  use  of  drugs  or  alcohol,  the  children 
may  be  hysteric  or  neurasthenic  or  epileptic  or  subject  to  any  one 
of  several  forms  of  insanity.  These  interchangeable  neuroses 
follow  Mendel's  law  quite  closely. 

The  next  most  important  factor  in  causing  hysteria  is  a  bad 
education.  The  only  child  is  especially  liable  to  hysteria,  as  is 
the  child  with  brothers  and  sisters  much  older  or,  indeed,  any 
child  unduly  pampered  by  the  other  members  of  the  family.  As 
a  result,  consideration  for  others  has  no  place,  or  only  a  very  small 
place,  in  their  ideas.  Physiologically,  it  may  be  said  that  the 
neuronic  relations  of  the  left  frontal  lobes  are  excessively  devel- 
oped at  the  expense  of  general  cerebral  balance.  As  the  result  of 
this  inflated  egocentric  psychology,  there  is  a  tendency  for  every 
sensory  impulse  to  be  immediately  transferred  into  a  personal 
and  emotional  expression,  either  word  or  deed.  Given  the  unbal- 
anced nervous  control,  exciting  causes  which  would  not  interfere 
to  any  great  extent  with  the  heafth  of  a  normal  individual  may 

391 


392  FUNCTIONAL  NEUROSES 

have  very  profound  and  serious  effects.    The  repressed  emotions , 
and  wishes  so  often  exaggerated  by  the  followers  of  Freud  occur 
before  puberty,  as  a  general  thing. 

The  stress  of  modern  education  is  an  important  factor  espe- 
cially in  girls.  High  school  buildings  are  often  badly  arranged. 
Class  rooms  scattered  from  the  basement  to  the  fourth  story  and 
connected  by  steep  and  winding  stairs,  crowded  and  unpleasant 
toilet  and  dressing  rooms,  together  with  the  need  for  too  much 
home  work,  are  certainly  enough  to  interfere  with  the  normal 
development  of  adolescent  nerve  centers,  but  when  these  are 
further  complicated  by  the  emotional  storms  incident  to  fraternity 
and  sorority  associations,  social  affairs,  music,  art,  and  dancing, 
the  problem  becomes  too  complex  for  any  ordinary  brain  to  meet 
in  an  efficient  manner.  Girls  have  the  worst  of  all  this ;  boys  usually 
have  outdoor  sports,  girls  may  have  these  but  household  cares, 
needle  work,  and  devotion  to  personal  appearance  add  further  com- 
plications. 

During  adolescence,  the  first  love  affairs,  religious  experiences, 
and  more  or  less  freakish  ambitions  may  initiate  hysteria.  The 
exciting  cause  of  any  attack  is  usually  absurdly  trivial.  It  is 
indeed  "the  last  straw  that  breaks  the  camel's  back"  in  these  cases. 
Recovery  from  any  given  attack  may  also  be  secured  by  apparently 
trivial  causes. 

Spinal  Conditions.  The  hysterical  spine  is  usually  very  irregu- 
lar. No  two  are  alike.  Lesions  of  the  occiput,  atlas  and  axis  are 
almost  universal.  Lesions  of  the  mandible  are  frequent.  Rib 
lesions  are  often  associated  with  improper  habits  of  breathing.  It 
is  very  rare  to  find  a  hysterical  patfent  whose  respiratory  muscles 
are  free  and  whose  respiratory  excursion  exceeds  one-half  inch  in 
quiet  breathing.  Lesions  of  the  coccyx  are  usually  present.  Many 
cases  called  hysterical  coccygodinia  are  really  due  to  misplaced 
coccyx  and  not  to  the  hysteria.  Given  the  hysterical  temperament, 
the  symptoms  which  cause  greatest  distress  are  frequently  localized 
through  the  influence  of  bony  lesions  which  may  be  the  result 
either  of  accident  or  of  reflex  muscular  contractions. 

Diagnosis.  True  hysteria  is  rather  rare.  Hysterical  symptoms 
associated  with  organic  diseases  almost  anywhere  in  the  body  are 
so  common  that  it  is  rather  rare  to  find  a  patient  who  has  been 
sick  for  months  or  years  whose  symptoms  are  not  somewhat  modi- 
fied by  unbalanced  neuronic  activity.  A  diagnosis  of  hysteria  alone 
can  only  be  made  when  every  organic  disease  has  been  found  to 
be  absent.  The  symptoms  of  hysteria  are  so  varied  that  this  fact 
itself  is  of  a  certain  value  in  diagnosis,  though  it  must  constantly 
be  remembered  that  many  organic  diseases  of  the  nervous  system 
as  well  as  of  many  visceral  organs  are  associated  with  hysterical 
symptoms. 


HYSTERIA  393 

Hysterical  phenomena  are  classified  according  to  the  structures 
chiefly  affected. 

The  memory  of  the  hysterical  patient  shows  many  lacunae; 
doubtless  this  accounts  for  the  many  variations  in  behavior.  Mul- 
tiple personality  depends  largely  upon  this  state,  as  does  the  exist- 
ence of  split  personalities,  buried  complexes,  and  the  various 
peculiar  antipathies  of  these  patients. 

Variations  in  consciousness  include  trances,  twilight  states, 
somnambulism  and  sleep-like  states  which*  may  continue  for 
months  at  a  time.  Remarkable  visions  are  often  associated  with 
these  lapses  of  consciousness. 

Hysterical  paralysis  may  have  a  sudden  onset  following  some 
emotional  shock  or  strain,  or  it  may  begin  insidiously  with  grad- 
ually increasing  weakness  of  certain  muscle  groups.  The  par- 
alysis may  be  either  flaccid  or  spastic.  It  may  continue  for  many 
years  until  the  limbs  involved  become  fixed  by  contractures  and 
by  changes  in  the  articular  tissues.  The  muscles  involved  do  not 
show  atrophy  or  any  marked  electrical  variations,  and  reflex  action 
may  be  increased,  diminished  or  lost.  Paralytic  muscular  contrac- 
tions disappear  under  anesthesia  and  during  sleep.  It  is  rare  for 
the  contractions  to  persist  through  accident,  especially  if  this  per- 
sistance  should  be  about  to  result  in  fracture  or  other  serious 
injury  to  the  body. 

Hysteric  paralysis  often  disappears  under  the  influence  of  shock. 
Attempts  have  been  made  to  cure  the  condition  by  providing 
apparently  accidental  catastrophes;  as,  for  example,  leaving  a 
patient  in  the  house  alone  and  then  providing  a  strong  smell  of 
smoke.  It  is  needless  to  say  that  attempts  of  this  sort  usually 
result  disastrously.   . 

Disturbed  cutaneous  sensations  are  almost  invariably  present 
and  are  usually  rather  strictly  localized.  Modified  sensations  are 
more  common  than  total  anesthesia.  This  accounts  for  the  peculiar 
response  which  such  patients  make  to  tests  of  sensation ;  for 
example,  if  a  patient  is  blind-folded  and  is  told  to  tell  when  she 
feels  a  touch  upon  any  part  of  the  body,  as  the  arms,  she  may 
respond  "Yes"  to  a  touch  upon  the  right  arm  and  "No"  to  a  touch 
upon  the  left  arm.  The  fact  that  the  answer  "No"  is  made  to 
a  touch  upon  the  left  arm  proves,  of  course,  that  it  was  perceived 
in  some  way.  The  disturbed  cutaneous  sensations  do  not  follow 
the  distribution  of  the  nerve  trunks,  nor  of  the  spinal  segments. 
They  do  correspond  rather  closely  to  the  cerebral  localization  of 
the  sensations  affected.  Disturbances  of  touch  and  pain  sensations 
are  the  most  frequent  and  most  marked.  Disturbances  of  muscle 
sense,  temperature  sense  and  of  the  peculiar  sensations  produced 
by  the  electrical  current  are  less  frequent  and  the  tests  for  these* 
sensations  are  decidedly  unsatisfactory. 


394  FUNCTIONAL  NEUROSES 

Disturbances  of  smell  and  taste  are  usually  present.  Odors 
which  have  been  previously  considered  pleasant  are  likely  to  be- 
come obnoxious.  Hyperosmia  is  not  rare.  One  patient  in  the 
P.  C.  O.  clinic  was  able  to  tell  whether  any  one  of  her  acquaint- 
ances had  been  in  a  room  within  the  last  hour  or  more,  by  the 
personal  odor.  She  was  not  able  to  follow  odors  in  the  open  air. 
Anosmia  occasionally  occurs.  Perverted  sense  of  taste  is  less 
frequently  found  and  it  is  usually  a  disturbance  of  the  olfactory 
sense,  rather  than  qf  taste,  that  is  present.  When  a  persistent 
sweet  taste  or  bitter  taste  is  complained  of  some  visceral  disease 
should  be  suspeced.  Occasionally,  however,  these  taste  perver- 
sions are  present  as  hysterical  phenomena. 

Deafness  and  tinnitus  are  not  frequent.  Occasionally  hallucina- 
tions of  hearing  occur.  Visual  disturbances  are  usually  present. 
Quivering  lights,  flashing  alternations  of  light  and  darkness,  dip- 
lopia and  other  transient  phenomena  are  very  frequent.  Unilateral 
blindness  and  amblyopia  occur  at  intervals.  Total  blindness  of 
sudden  onset  may  last  for  minutes  or  for  years,  and  may  disappear 
suddenly.  Contraction  of  the  visual  fields  and  especially  of  the 
color  fields  is  so  constant  a  finding  that  it  is  of  diagnostic  value. 
The  retraction  of  the  color  fields  is  usually  concentric,  though 
often  the  blue-yellow  field  retracts  within  the  red-green  field.  The 
visual  field  may  be  so  retracted  that  the  patients  seem  to  be  look- 
ing through  a  tube — "tubular  vision."  This  condition  is  rarely 
suspected  until  the  examination  is  made. 

Disturbances  of  visceral  sensations  are  variable.  Lack  of  appe- 
tite, voracity,  lack  of  thirst,  polydipsia,  very  severe  causeless  vis- 
ceral pain,  anesthesia  in  severe  visceral  diseases  ordinarily  painful, 
sexual  frigidity,  nymphomania  or  satyriasis,  may  be  found  in  dif- 
ferent individuals  or  in  the  same  individual  at  different  times. 

The  blood  in  hysterical  patients  is  usually  good.  The  hemo- 
globin, erythrocyte  count,  and  leucocyte  count  are  usually  prac- 
tically normal.  The  individual  cells,  however,  frequently  show  the 
characteristics  of  immature  blood.  A  few  nucleated  red  cells  and 
immature  forms  of  the  white  cells  are  found  in  those  cases  in  which 
the  hereditary  or  congenital  factor  is  pronounced. 

The  examination  of  the  urine  shows  usually  a  diminished  excre- 
tion of  solids.  Phosphates  are  frequently  increased  and  calcium 
oxalate  crystals  are  often  present.  After  a  hysterical  crisis  large 
amounts  of  urine  of  low  specific  gravity  are  usually  voided.  This 
serves  to  distinguish  certain  doubtful  cases  of  hysteria  from 
epilepsy. 

Crises.  The  fits  or  convulsive  attacks,  called  crises,  described 
with  so  great  detail  by  Charcot  and  other  of  the  Salpetriere  school, 
are  rarely  found  in  this  country.  These  are  usually  precipitated 
by  some  emotion  or  fatigue  but  may  be  self-originating.     They 


HYSTERIA  395 

rarely  resemble  epileptic  fits  quite  closely.  They  usually  last' 
longer  than  epileptic  attacks ;  the  movements  have  a  purposive 
appearance  and  usually  imitate  the  expression  of  some  profound 
emotion  or  passion.  The  hysterical  patient  rarely  bites  the  tongue, 
injures  the  body  in  any  way,  froths  at  the  mouth  or  passes  urine 
and  feces  involuntarily.  The  hysterical  patient  is  usually  bright 
and  appears  to  feel  very  well  after  the  attack.  Very  different 
conditions  are  associated  with  the  epileptic  fit.  (q.  v.) 

Pseudohydrophobia  (Lyssophobia)  occurs  in  neurotic  persons 
after  having  been  bitten  by  a  dog,  or  even  after  having  been 
frightened  by  a  dog  or  any  other  animal.  The  use  of  the  term 
"mad-dog"  has  caused  virulence  to  be  imputed  to  the  saliva  of 
any  infuriated  animal  even  though  perfectly  healthy.  The  symp- 
toms of  hydrophobia  are  greatly  exaggerated  in  imagination.  Some 
weeks,  months,  or  years  after  the  fright,  usually  upon  some  un- 
pleasant occurrence,  the  patient  begins  to  complain  of  feeling  ill. 
The  site  of  the  wound  may  become  painful,  occasionally  even  red- 
dened slightly.  The  patient  often  bites  at  the  old  wound,  or  at 
the  site  of  an  imagined  wound,  until  it  becomes  decidedly  sore, 
perhaps  infected.  A  horror  of  water  is  urgent,  and  the  patient 
struggles,  bites  and  snaps  like  a  dog,  and  imitates  whatever  symp- 
toms of  hydrophobia  he  may  have  heard  of,  or  imagined.  Only 
under  unusual  conditions  is  there  difficulty  in  making  a  differen- 
tial diagnosis  between  this  form  of  hysteria  and  true  hydrophobia. 

Pseudomeningitis.  Spinal  meningitis  lends  itself  readily  to  imi- 
tation by  patients  with  the  hysterical  love  of  the  spectacular.  It 
is  found  most  often  in  girls  and  young  women;  especially  if  they 
consider  themselves  hopelessly  in  love.  A  death  from  "brain  fever" 
sounds  delightfully  tragic ;  and  their  neurotic  symptoms  lead  them 
really  to  believe  themselves  seriously  ill.  The  hysterical  mus- 
cular contractions  lead  easily  to  opisthotonos ;  nausea  and  vomiting 
are  easily  encouraged ;  the  fanciful  or  sportive  or  maudlin  delirium 
of  true  meningitis  is  not  unlike  the  natural  expression  of  the 
hysterical  love-lorn  maiden.  The  hysteria  is  easily  recognized 
unless  the  diagnosis  of  meningitis  is  accepted  by  an  unsuspicious 
physician. 

Treatment.  The  essential  thing,  in  treatment,  is  to  provide, 
first  a  normal  circulation  of  normal  blood  through  the  brain,  sec- 
ond, a  normal  stream  of  nerve  impulses  leading  to  a  reeducation 
of  the  brain  centers.  The  exact  methods  to  be  employed  vary  for 
each  individual,  and  must  be  based  upon  a  physical  and  mental 
examination. 

The  spinal  and  costal  lesions  should  be  corrected  by  means  of 
movements  which  do  not  add  to  the  irritation  of  the  conditions 
already  present.     Care  must  be  taken  in  giving  the  osteopathic 


396  FUNCTIONAL  NEUROSES 

treatrtient  to  avoid  securing  too  great  relaxation  of  the  spinal  liga- 
ments. It  is  necessary  also  to  avoid  the  "treatment  habit."  Hyster- 
ical patients  too  often  find  themselves  impressed  with  the  need 
for  corrective  treatment  and  go  from  one  doctor  to  another,  con- 
stantly seeking  heavier  or  more  gentle  or  more  efficient  treatments. 

Patients  who  are  emaciated,  weak  or  anemic  may  have  the  rest 
cure  such  as  is  found  beneficial  in  neurasthenia,  (q.  v.)  Those 
whose  bodies  show  good  nutrition  and  in  whom  the  blood  pressure 
is  low,  are  best  benefited  by  being  sent  out  doors  and  hy  being 
given  exercises  which  lead  to  the  development  of  the  muscles. 

The  next  most  important  factor  in  the  treatment  of  hysterical 
patients  is  found  in  reeducation.  It  is  necessary  that  the  whole 
trend  of  thought  should  be  changed  from  the  egocentric,  to  the 
altruistic.  This  is  not  best  done  by  attempting  to  appeal  to  the 
generous  emotions,  since  this  leads  rather  to  further  self-pity,  or 
to  the  development  of  the  "martyr"  idea.  Any  sort  of  fad  which 
leads  to  out-of-door  work  may  be  encouraged.  Change  of  scene 
is  frequently  recommended;  to  be  efficient  it  should  be  complete. 
The  one^who  seeks  a  change  of  scene,  carrying  with  her  her  maid, 
her  pet  dog  and  everything  which  has  kept  her  mind  wrapped 
in  cotton  wool  through  all  her  life  long  is  not  likely  to  find  a 
change  of  scene  in  any  proper  sense,  whether  she  goes  to  Green- 
land or  to  India. 

In  those  cases  in  whom  some  emotional  shock  has  been  the 
original  cause  of  the  disease,  some  methods  of  psychoanalysis  may 
be  employed.  There  is  no  question  that  some  hysterias  do  rest 
upon  a  basis  of  repressed  feelings,  either  sexual,  religious,  or  other. 
In  such  cases  the  complete  exposure  and  discussion  of  the  varied 
complexes  frequently  results  in  recovery  which  appears  almost 
unbelievable.  On  the  other  hand  patients  whose  condition  rests 
upon  some  other  etiological  factor  are  too  often  put  through  a 
series  of  unpleasant  discussions,  whose  only  effect  is  to  transfer 
the  symptoms  into  the  psycho-sexual  sphere.  For  this  and  other 
reasons  it  is  best  that  these  methods  should  first  be  employed  by  the 
physician  in  charge  of  the  patient,  and  without  explaining  the  rea- 
son for  the  various  discussions.  Much  more  frankness  is  secured, 
from  most  patients,  by  asking  questions,  either  directly  or  indi- 
rectly, after  the  treatment  has  been  given,  while  the  patient  still 
lies  upon  the  table.  The  variations  in  pulse  rate  and  in  blood 
pressure  are  valuable  in  recognizing  significant  statements  or 
evasions.  Psychoanalytic  methods  require  much  time  and  a  cer- 
tain amount  of  skill  and  sympathy.  When  any  physician  finds  him- 
self unable  to  give  these,  or  when  his  best  efi^orts  fail,  it  is  much 
better  to  send  the  patient  to  a  professional  psychoanalyst  for  that 
special  line  of  educational  work.  The  correction  of  the  structural 
perversions  can  be  done,  either  before,  during,  or  after  the  analysis 
of  the  mental  content.    In  any  case,  the  structural  perversions  must 


HYSTERIA  397 

be  corrected,  else  later  attacks,  though  of  different  symptoms,  may- 
be expected. 

During  a  crisis,  the  patient  should  usually  be  left  alone.  When 
the  symptoms  are  very  severe,  some  treatment  may  be  required; 
this  is  palliative  and  symptomatic.  Very  slow  and  strong  spinal 
extension  is  often  useful.  A  neutral  bath,  continued  for  one  or 
several  hours,  may  relieve  convulsions.  Rest  in  a  dark  room  is  gen- 
erally the  very  best  thing.  No  atmosphere  of  excitement  is  permis- 
sible ;  nor  is  any  sense  of  punishment  to  be  manifested.  Scoldings 
may  avert  an  attack,  in  the  very  beginning,  in  mild  cases,  but  these 
usually  exacerbate  the  fit  and  intensify  the  neurosis.  Commonly 
following  an  emotional  storm  the  patient  feels  decidedly  refreshed. 

It  is  rarely  useful  to  treat  symptoms  directly,  unless  there  is 
some  organic  disease  present.  Bony  lesions  may  be  responsible 
for  various  functional  diseases  of  the  various  organs;  correction 
of  the  lesions,  with  or  without  an  explanation  of  the  desired  effects, 
is  all  that  is  needed  for  these  conditions.  Functional  diseases  of 
certain  organs,  especially  gastro-intestinal  or  genito-urinary,  may 
be  due  to  the  hysteria  alone ;  in  such  cases,  the  less  said  about  the 
disease,  after  one  discussion  and  explanation,  the  better.  Espe- 
cially in  neurotic  girls  and  unhappily  married  women  should  the 
discussion  and  treatment  of  the  pelvic  organs  be  evaded.  When 
serious  organic  disease  is  present  the  condition  should  be  properly 
treated;  when  the  pelvic  conditions  are  secondary  to  the  neurosis, 
local  treatment  should  be  postponed  until  better  nervous  control  is 
reestablished. 

Sensory  disturbances  usually  need  no  treatment;  when  they 
are  severe,  massage,  counter-irritation,  electricity,  or  sun-baths, 
may  be  recommended.  Motor  disturbances  also  may  be  disre- 
garded, unless  pain  or  great  inconvenience  is  caused.  Bandages, 
adhesive  straps,  electricity,  warm  baths,  may  give  temporary  relief. 
Orthopedic  measures  usually  do  more  harm  than  good ;  after  the 
neurotic  condition  has  been  completely  overcome,  if  structural 
deformities  persist,  orthopedic  surgery  may  be  necessary. 

It  is  too  frequently  the  case  that  doctors  and  nurses,  as  well 
as  the  members  of  the  family,  consider  hysteria  merely  another 
form  of  malingering.  They  think  that  the  hysteric  patient  could 
be  all  right  if  she  would,  which  may  be  true,  but  it  is  also  true 
that  she  "can't  would."  No  doctor  should  assume  charge  of  a 
case  of  hysteria  unless  he  can  deal  with  the  condition  in  just  the 
same  impersonal  and  scientific  and  kindly  way  that  he  would  use 
in  dealing  with  a  patient  who  suffers  from  any  other  disease.  The 
pain  in  hysteria  is  as  severe  and  distressing  as  is  the  pain  in  any 
other  disease;  the  paralysis  is  as  inevitable  as  it  is  in  poliomyelitis. 
Unless  one  is  willing  to  give  attention  and  thought  to  the  disease 
in  a  professional  and  scientific  manner  he  should  not  attempt  to 


398  FUNCTIONAL  NEUROSES 

care  for  these  cases,  but  should  refer  them  to  some  other  physician 
who  is  willing  to  treat  the  case  properly. 

Prognosis.  With  proper  care,  the  prognosis  for  recovery  is 
good  so  far  as  the  symptoms  are  concerned.  Inasmuch  as  the 
condition  rests  upon  a  constitutional  foundation,  it  is  evident  that 
this  must  persist  throughout  life,  but  with  ordinary  care  and  good 
hygienic  living  these  patients  should  complete  long,  happy,  useful 
lives. 

THE  NEURASTHENIC  STATES 

The  term  neurasthenia  is  somewhat  vaguely  applied  to  a  func- 
tional nervous  disease  which  is  characterized  by  symptoms  of 
fatigue  of  the  certain  groups  of  nerve  centers. 

Pathology.  The  structural  changes  are  at  present  extremely  doubtful. 
Chromatdlysis  of  the  motor  neurons  has  been  described.  Functionally  there  is 
an  increased  irritability  and  increased  fatigability  of  the  nerve  centers.  The 
muscles  are  not  fatigued  as  is  indicated  from  the  manner  in  which  they  react 
to  direct  electrical  stimulation.  The  reflexes  are  first  increased  but  speedily 
diminished. 

Etiology.  Both  predisposing  and  exciting  causes  must  be  rec- 
ognized. Of  the  first  by  far  the  most  important  is  heredity^;  it  is 
very  rare  to  find  a  typical  neurasthenic  in  a  family  whose  ances- 
tors are  all  nervously  sound.  Alcoholism,  syphilis,  tuberculosis, 
extreme  youth,  old  age,  drug  addictions,  migraine,  hysteria  often 
occur  in  the  parents  or  are  characteristic  of  the  ancestry  of  the 
neurasthenic  patient.  When  these  conditions  are  variously  com- 
bined in  both  parents  or  grandparents  only  a  normal  life  can 
prevent  the  occurrence  of  the  neurasthenia  or  other  neurosis  in 
the  children.  Other  predisposing  causes  are  the  use  of  stimulants, 
and  unhygienic  living;  overwork  has  been  greatly  exaggerated  as 
the  cause  of  neurasthenia.  It  seems  certain  that  no  amount  of 
mental  overwork  or  responsibility  causes  neurasthenic  states  in 
an  individual  who  has  proper  hours  of  sleep  and  of  outdoor  exer- 
cise and  whose  food  is  that  best  adapted  to  his  manner  of  living; 
in  other  words  work  which  does  not  interfere  with  hygiene  prob- 
ably is  never  excessive.  The  overwork  which  is  associated  with 
an  undue  sense  of  responsibility,  which  causes  unrest  and  worry 
often  leads  to  the  use  of  stimulants.  Work  which  is  never  satis- 
factorily completed  causes  a  troublesome  sense  of  inefficiency,  and 
this  in  turn  often  leads  to  the  use  of  sedatives  and  stimulating 
drugs. 

"It  must  not  be  forgotten  that  it  is  not  the  work  which  injures;  probably 
persons  injured  by  overwork  are  rarely  found;  but  it  is  the  lack  of  sleep, 
out-of-door  exercise,  the  overeating,  either  of  overly  rich  food  or  the  food  of 
some  faddist,  it  is  the  lack  of  proper  hygienic  habits  which  bring  the  trouble. 
The  person  who  has  good  food,  good  air,  good  exercise  and  a  body  whose  parts 
are  properly  related,  who  eats,  sleeps,  laughs,  and  plays  enough,  has  no  time 
for  overwork  and  is  not  apt  to  overworry." — L.  Burns.     -• 


NEURASTHENIA  399 

"Diflferent  cases  present  different  lesions,  and  no  typical  lesion  may  be 
described  for  all  cases,  but  certain  lesions  are  common,  in  the  various  types ;  as 
cervical  and  upper  dorsal  in  the  cerebral;  mid-dorsal  and  ribs,  in  the  gastric; 
lower  dorsal,  ribs,  and  upper  lumbar,  in  the  intestinal.  Upper  cervical  and  upper 
dorsal  lesions  seem  to  be  most  constant  in  the  spinal  and  sympathetic  variety. 
The  lesion  of  third  and  fourth  cervical  to  the  right  (reported  by  Hazzard  and 
also  by  McConnell  and  Teall)  seems  responsible  in  many  of  my  own  cases  for 
the  cerebral  symptoms,  except,  possibly,  the  vertigo  which  may,  and  generally 
does,  result  from  atlas  displacement." — C.  A.  Champlin. 

"The  neurasthenic  complexes  are  formed  by  education,  and  like  useful  or 
normal  complexes,  such  as  those  of  motion  in  piano  playing,  require  time  and 
repetition  in  formation.  The  basis  of  these  complexes  may  be  formed  without 
intention,  by  accident,  or  by  environment.  The  conditions  favoring  its  forma- 
tion are  repeated  frequently  and  enlarged  upon  until  it  is  often  very  hard  to 
recognize  the  basic  causative  factor.  If  this  was  brought  about  by  education, 
it  requires  reeducation  to  show  the  patient  wherein  the  misconception  of  his 
condition  started.  If  we  can  trace  for  a  patient  from  the  beginning  the  suc- 
cessive steps  that  have  led  to  his  present  condition,  we  have  gained  in  the 
understanding  of  his  case  and  in  starting  him  on  the  road  to  recovery.  But  we 
must  regard  such  a  case  as  disease  and  treat  it  as  such,  and  see  that  the  family 
looks  upon  the  patient  as  sick,  not,  as  is  frequently  said,  suffering  from  lack  of 
self-control." — C.  E.  Farnum. 

"In  run-down  neurasthenic  patients,  anemic  or  not,  the  blood  pressure  is 
apt  to  be  too  high  or  low.  Its  level  will  determine  absolutely  the  dietetic  and 
hygienic  treatment ;  its  reaction  will  determine  the  osteopathic  treatment,  fre- 
quency, and  severity." — L.  G.  Robb. 

Bony  Lesions.  The  characteristic  neurasthenic  spine  is  rigid 
and  flat  through  its  entire  extent.  The  various  lateral  subluxations 
of  individual  vertebrae  and  long  slight  curves  and  rotations  may 
be  present,  but  the  flatness  is  characteristic.  The  irregular  cervi- 
cal spinal  column  is  frequently  important  in  the  cerebral  or  mental 
types.  Coccygeal  lesions  and  innominate  lesions  are  most  com- 
mon in  the  sexual  neurasthenics;  depressed  lower  ribs  are  prac- 
tically constant,  the  eleventh  rib  stands  out  and  the  twelfth  rib 
usually  lies  within  the  iliac  crest. 

Areas  of  hypersensitiveness  are  variable  in  location  and  in 
degree.  Often  the  tissues  along  the  spinal  column  and  the  angles 
of  the  ribs  are  practically  anesthetic  at  the  first  examination, 
becoming  increasingly  hyperesthetic  as  the  increased  mobility, 
resulting  from  the  treatment,  permits  the  more  normal  activity  of 
the  spinal  centers  concerned  in  carrying  sensations  of  heat,  cold 
and  pain  upward  to  the  brain.  There  is  no  question  that  the 
spinal  condition  is  an  important  etiological  factor  in  the  neuras- 
thenic states. 

Diagnosis.  The  onset  of  the  disease  is  usually  gradual ;  it 
begins  with  a  tendency  to  fatigue  more  easily;  there  is  some 
insomnia  and  irritability  of  temper.  Very  frequently  these  condi- 
tions follow  a  prodromal  period  of  unusually  strenuous  living,  dur- 
ing which  time  the  patient  sleeps  less  and  indulges  himself  more 
than  is  proper  in  pursuing  ambition  or  pleasure.  The  fatigability, 
insomnia  and  irritability  grow  worse,  a  sense  of  pressure  in  various 


400  FUNCTIONAL  NEUROSES 

parts  of  the  body  is  frequent,  this  gives  rise  to  the  sensation  called 
"stocking  sensation,"  "glove  sensation,"  rarely  "girdle  sensation" 
and  the  "lead-cap  headache."  Sensations  geometrically  outlined 
are  very  apt  to  be  neurasthenic.  The  sense  of  fatigue  is  worse  in 
the  morning.  During  the  day,  meeting  other  people  and  amid  the 
emergencies  of  work  and  play,  the  patient  feels  more  and  more 
able  to  meet  the  demands  of  living.  By  night  he  is  often  very 
much  alive  and  ready  for  anything  except  sleep. 

The  insomnia  is  characteristic.  The  depth  of  normal  sleep  is 
very  profound  for  the  first  two  hours  or  so  of  the  night,  the  level 
then  returns  almost  to  the  waking  line  and  remains  fairly  constant 
until  early  morning,  the  depth  of  sleep  increases  at  this  time 
usually  to  a  point  about  one  half  that  of  the  earlier  depth  and 
this  terminates  by  awaking.  The  neurasthenic  has  only  the  two 
"drops"  for  his  sleep  period;  those  hours  which  a  normal  person 
passes  in  shallow  sleep  the  neurasthenic  passes  in  Avakefulness. 
This  daily  history  is  in  itself  almost  pathognomonic.  Besides  the 
general  symptoms  just  given  neurasthenic  patients  are  subject  to 
various  other  symptoms,  referable  to  different  organs. 

In  the  gastric  type  the  patient  complains  profoundly  of  diges- 
tive disturbances.  It  is  extremely  difficult  to  make  a  certain  diag- 
nosis of  this  form  of  neurasthenia  because  of  the  difficulty  of 
eliminating  organic  stomach  disease.  Gastrectasis  is  eliminated 
with  difficulty  because  the  neurasthenic  has  usually  relaxed  and 
atonic  abdominal  and  gastric  muscular  walls.  Accumulations  of 
gas  within  the  stomach  are  quite  constant.  X-ray  pictures  taken 
during  the  digestion  of  a  contrast  meal  give  the  most  satisfactory 
diagnostic  information.  Reflex  muscular  contraction,  bony  lesions 
and  hyperesthetic  areas  are  to  be  found  from  the  fifth  to  the  tenth 
thoracic  vertebrae  and  the  corresponding  costal  areas. 

Cardiac  Type:  Vasomptor  Type.  Neurasthenic  disturbances 
of  the  circulation  are  characterized  by  a  weakness  in  the  heart's 
beat,  low  blood  pressure,  slow  circulation,  cold  hands  and  feet 
and  pallor  of  the  conjunctivae  and  mucous  membranes.  This  pallor 
may  be  so  marked  as  to  suggest  profound  anemia ;  the  examination 
of  the  blood,  however,  easily  eliminates  any  form  of  anemia.  It  is 
less  easy  to  make  a  satisfactory  diagnosis  of  the  cardiac  condition. 
The  weakened  muscle  walls  and  the  diminished  force  of  systole 
are  probably  responsible  for  the  hemic  murmurs  so  frequently 
found  in  neurasthenics.  The  hypersensitiveness  and  bony  lesions 
are  found  in  the  second  to  the  fourth  thoracic  region  and  in  the 
upper  cervical  vertebrae. 

Sexual  Type.  This  is  one  of  the  most  common  types  of  neuras- 
thenia among  men.  Sexual  overactivity  and  sexual  perversions 
are  certainly  factors  in  this  form  of  neurasthenia  but  their  plaice 
in  etiology  has  been  very  greatly  overestimated.     It  is  far  more 


NEURASTHENIA  401 

frequently  the  case  that  the  lack  of  self-control  associated  with 
the  neurasthenic  state  is  responsible  for  the  sexual  wrongdoing 
than  that  these  initiate  the  neurasthenic  state.  There  is  no  question, 
however,  that  sexual  perversions  and  excesses  do  increase  the 
neurasthenic  symptoms  most  profoundly,  especially  in  men.  In 
women  the  injury  seems  to  be  more  often  due  to  unrecognized 
desire  rather  than  as  the  result  of  overindulgence.  The  evil  effects 
of  day-dreaming,  romantic  literature,  and  all  of  the  emotionally 
morbid  surroundings  to  which  women  of  idle  lives  are  often  ad- 
dicted, are  extremely  injurious  to  the  nerve  centers  of  the  lum- 
bo-sacral  enlargement.  Lesions  of  the  lumbar  vertebrae,  the  in- 
nominates  and  coccyx  are  almost  universal  in  these  cases.  The 
neurasthenic  state  as  well  as  the  bony  lesions  mentioned  exert  a 
harmful  effect  upon  the  pelvic  organs.  Lax  muscles  and  ligaments, 
congested  ovaries,  heavy,  soft  uterus,  are  usually  present  in  neu- 
rasthenic women.  When  the  infantile  uterus  and  poorly  developed 
sexual  organs  are  found  in  women  hysteria  is  rather  more  apt  to 
occur  than  neurasthenia.  In  men  sexual  desire  is  sometimes 
increased,  premature  erections  and  emissions  are  frequent,  satis- 
factory intercourse  is  often  impossible,  and  in  both  sexes  inter- 
course is  frequently  followed  by  profound  exhaustion  and  distaste. 
Marital  unhappiness  produced  by  this  condition  frequently  adds 
to  the  general  nervous  malfunction. 

Cerebral  Type;  Psychasthenia.  This  type  sometimes  exists 
with  very  little  sign  of  neurasthenia  as  affecting  the  rest  of  the 
body.  It  is  characterized  by  a  mental  exhaustion,  if  the  expression 
may  be  permitted.  The  patient  realizes  his  condition  but  finds 
himself  unable  to  maintain  the  interest  and  the  effort  necessary 
to  enable  him  to  do  the  work  to  which  he  is  accustomed  or  which 
he  desires  to  do.  The  mental  state  is  frequently  suggestive  of 
atavistic  phenomena.  Kleptomania,  or  the  passion  for  annexing  and 
secreting  objects  for  which  the  patient  cannot  possibly  have  any 
legitimate  use  is  one  of  these.  Mysophobia  or  the  horror  of  con- 
tamination is  probably  not  to  be  included  as  an  atavistic  phenom- 
enon. Agoraphobia,  the  fear  of  open  spaces;  claustrophobia,  the 
fear  of  closed  in  places ;  zoophilia  or  the  inordinate  love  of  animals, 
are  among  the  most  common  phenomena  whose  nature  suggests 
more  or  less  vividly  the  past  experience  of  the  race. 

Laboratory  Findings.  These  are  more  helpful  in  showing  the 
condition  of  the  individual  patient  than  in  naming  the  disease. 
The  amount  of  urine  varies ;  the  total  excretion  of  solids  is  usually 
low,  a  retention  of  uric  acid  and  other  purins  is  very  common. 
Calcium  oxalate  is  present  in  a  great  many  cases  and  it  indicates 
the  deficient  oxidation  present  occurring  in  the  body.  Phospha- 
turia  is  frequently  present;  the  examination  of  urine  is  of  value  in 


402  FUNCTIONAL  NEUROSES 

the  differential  diagnosis  between  the  nervous  symptoms  due  to 
early  diabetes  or  nephritis  and  those  of  neurasthenia. 

The  blood  is  characteristic.  The  color  index  is  low;  this  is 
due  either  to  an  increase  in  the  number  of  red  cells  or  to  a 
decrease  in  the  hemoglobin  percentage.  The  red  cells  usually 
show 'irregularities  in  size,  shape  and  staining  reactions.  Among 
the  white  cells  the  most  conspicuous  change  is  the  relative  increase 
in  th,e  eosinophiles,  this  is  constant  and  is  oi  value  in  diagnosis. 
The  blood  changes  appear  to  be  due  to  the  lack  of  circulation 
through  the  red  bone  marrow,  especially  of  the  ribs.  Neuras- 
thenics rarely  breathe  properly,  the  respiratory  excursion  is  inva- 
riably diminished.  Blood  examination  is  useful  in  making  the 
differential  diagnosis  between  the  nervous  states  of  secondary 
anemia,  pernicious  anemia,  chlorosis,  the  leukemias,  all  of  which 
have  more  or  less  profound  nervous  disturbances,  and  true  neuras- 
thenia. 

Treatment.  The  correction  of  bony  lesions  as  found  is  impor- 
tant in  this  disease  but  this  is  rarely  sufficient  to  provide  all  condi- 
tions necessary  for  recovery.  ImJ)roved  nutrition,  improved  circu- 
lation through  the  spinal  cord,  improved  functional  activity  of  the 
nerve  cells,  all  of  which  result  from  the  increased  mobility  of  the 
spinal  column  and  the  raising  of  the  ribs  give  the  best  possible  con- 
ditions for  recovery  on  the  part  of  the  inefficient  spinal  neurons. 
On  the  other  hand  if  the  etiological  factors  are  constantly  throwing 
greater  burdens  upon  these  centers,  if  the  circulating  blood  is 
constantly  filled  with  the  toxins  resulting  from  bad  diet,  poor 
breathing,  and  insufficient  water  intake,  it  is  evident  that  the 
manipulation  alone  is  not  the  whole  of  osteopathic  treatment  in 
such  cases. 

In  suitable  cases  a  modified  form  of  the  Weir-Mitchell  rest 
cure  with  a  full  milk  diet  works  wonders.  Rest  and  increased 
nutrition  of  the  nerve  centers  is  the  whole  matter  of  treatment. 
Increased  proteids,  increased  fats  and  increased  water  intake  are 
extremely  important  matters.  Starches  and  sugars  need  not  be 
increased.  The  raw  vegetables  in  the  form  of  salads  should  be 
added  freely  to  the  diet. 

In  many  cases  it  is  better  to  lessen  the  amount  of  work  but 
not  to  take  it  away  altogether.  Very  frequently  the  relief  from 
responsibility  is  all  that  is  necessar.y  If  the  work  performed  is 
kept  within  the  limit  of  that  which  can  be  satisfactorily  completed 
day  by  day,  leaving  time  for  a  few  hours  of  outdoor  exercise,  most 
patients  do  better  than  when  they  suffer  the  humiliation  and  dis- 
comfort of  being  removed  completely  from  work  which  has  hereto- 
fore occupied  a  very  great  part  of  the  waking  hours. 

In  other  cases  a  complete  change  of  scene  is  necessary;  this  is 
especially  true  when  the  patient  has  no  great  amount  of  interest 


TRA  UMA  TIC  NB UROSES  403 

in  the  work  which  he  has  been  doing.  The  change  of  scene  must 
be  truly  a  change.  The  patient  who  goes  to  another  climate  carry- 
ing with  him  his  family  or  servants,  who  eats  the  same  food,  affects 
the  same  dissipation,  drinks  the  same  drinks  and  stays  up  to  the 
same  unholy  hours  at  night,  finds  no  change  of  scene  even  though 
he  should  travel  from  the  equator  to  the  pole.  The  great  value  of 
a  visit  to  the  various  hot  springs  and  health  resorts  comes  as 
much  from  the  fact  that  change  in  occupation  and  thought  and  a 
physiological  division  of  the  day  are  insisted  upon  as  from  any 
other  factors.  The  patient  must  be  taught  that  his  mental  atti- 
tude is  an  important  factor  in  the  insomnia,  and,  to  a  certain  extent, 
in  the  other  symptoms. 

Prognosis.  Neurasthenia  rarely  terminates  life  either  directly 
or  indirectly ;  indeed,  the  disease  itself  lessens  the  exposure  to  the 
ordinary  dangers  of  living.  A  recovery  from  any  given  attack  is 
certain  if  the  patient  will  willingly  obey  directions  and  receive 
the  proper  treatment  for  his  condition.  Future  attacks  are  to  be 
avoided  only  by  avoiding  the  causes  as  mentioned  above.  Neuras- 
thenics and  those  who  have  suffered  from  neurasthenic  attacks 
should  not  marry  other  neurasthenics.  The  mildly  neurasthenic 
may  safely  marry  persons  with  sound  and  wholesome  nervous  sys- 
tems. The  children  of  such  marriages  are  often  all  that  is  to  be 
desired  in  the  way  of  health  and  usefulness. 


TRAUMATIC  NEUROSES 

The  term  "traumatic  neuroses"  is  applied  to  those  disturbances 
of  the  nervous  system  following  shocks  or  accidents,  but  not  asso-* 
ciated  with  gross  lesions  of  the  nerves,  the  brain  or  the  spinal  cord. 
The  shock  is  usually  associated  with  some  concussion  and  with 
very  profound  fright  or  excitement.  Frequently  the  symptoms  do 
not  appear  for  some  hours  or  even  days  after  the  accident.  The 
symptoms  are  sometimes  very  vague  and  may  present  an  extremely 
complicated  diagnostic  picture.  Disturbed  personality  such  as 
characterizes  neurasthenic  and  hysterical  states,  together  with 
various  sensory  and  motor  disturbances,  contractures  and  paralyses 
may  be  present.  The  complicated  nature  of  the  effects  produced 
by  accidents  often  leads  to  a  suspicion  of  bad  faith  and  malingering. 
There  is  no  question  that  people  who  have  been  in  railroad  or 
other  accidents  often  deliberately  magnify  the  results  of  the  injuries 
in  the  hope  of  securing  larger  amounts  of  money  in  payment  for 
the  damage  they  have  sustained.  Such  attempts  rarely  deceive 
any  earnest  investigator.  It  is  necessary  that  the  investigation  of 
these  cases  shall  be  pursued  in  such  a  way  as  to  protect  both  the 
victim  and  also  the  company  or  individual  who  has  the  duty  of 
paying  for  the  damages  inflicted ;  in  other  words,  it  is  the  duty  of 


404  FUNCTIONAL  NEUROSES 

the  physician,  in  such  cases,  to  seek  for  the  actual  truth  of  the 
condition.  If  he  makes  the  examination  in  a  frank  and  kindly 
manner,  it  is  usually  not  difficult  to  draw  the  line  between  even 
vague  and  complicated  nervous  results  of  accident  and  the  awkward 
attempts  at  deceit  which  are  usually  made  by  dishonest  persons. 

The  very  fact  of  litigation  causes  pronounced  nervous  disturb- 
ances of  a  functional  nature.  Railroads  and  other  companies 
responsible  for  accidents  frequently  have  the  date  of  trial  post- 
poned in  the  hope  that  the  recovery  of  the  injured  persons  may 
lessen  the  sense  of  injury.  It  is  true  also  that  with  the  lapse  of 
time  the  force  of  public  opinion  is  considerably  diminished.  All 
of  this  works  for  harm  to  the  patient.  In  order  that  the  most 
speedy  recovery  may  be  made  from  such  shocks,  the  financial 
aspect  of  the  case  should  be  settled  as  speedily  as  possible.  The 
fact  that  recovery  occurs  very  quickly  after  the  compromise  has 
been  effected,  or  the  court  procedures  have  been  fully  completed, 
is  often  held  as  evidence  that  the  patient  was  merely  a  pretender. 
This  is  a  serious  injustice,  since  it  is  often  the  relief  from  worry 
that  removes  the  last  obstacle  to  recovery. 

Pathology.  In  many  cases  in  which  death  has  followed  some  inter- 
current disease  after  such  shocks,  the  examination  of  the  brain  and  cord  shows 
slight  capillary  hemorrhages.  Concussion  certainly  causes  a  tremendous  shock 
to  sensory  neurons.  The  effects  of  these  may  be  very  serious  but  are  usually 
transient.  The  wrenches  of  the  bony  tissues  of  the  body  produced  by  acci- 
dents are  certainly  responsible  for  a  large  proportion  of  the  symptoms  found 
in  the  traumatic  neuroses.  Lesions  thus  produced  are  overlooked  by  the 
ordinary  doctor  of  medicine,  but  are  none  the  less  important  in  etiology. 
Lesions  of  the  occiput  and  upper  cervical  region  cause  various  disturbances  in 
mentality.  These  may  vary  from  a  slight  loss  of  self-control  to  severe  acute 
•confusional  insanity.  Lesions  of  the  upper  thoracic  region  cause  disturbances 
of  the  heart  action  and  various  vascular  disturbances.  Lesions  of  the  lower 
thoracic  region  affect  the  abdominal  viscera,  while  lesions  of  the  lower  cervical 
or  of  the  lumbar  spine  may  be  responsible  for  paralysis  and  for  sensory  dis- 
turbances. Lesions  affecting  the  dorso-lumbar  area  cause  disturbances  of  the 
circulation  and  secretion  of  the  kidneys  and  suprarenals.  Cervical  or  upper 
dorsal  lesions  may  cause  various  disturbances  of  the  eyes  and  of  the  ears.  The 
recognition  of  these  lesions  as  etiological  features  in  functional  diseases  of  the 
organs  named  above  and  their  correction  should  go  far  toward  promoting  recov- 
ery more  speedily  in  these  traumatic  neuroses. 

Treatment.  Bony  lesions  as  found  are  to  be  corrected  as 
speedily  as  is  possible  under  the  varying  circumstances.  After 
this,  the  most  important  factor  is  termination  of  litigation.  The 
treatment  for  neurasthenia  is  indicated,  (q.  v.) 


MIGRAINE 

(Hemicrania;  periodic  sick  headache) 

Migraine  is  a  functional  disease  of  the  nervous  system,  charac- 
terized by  periodical  attacks  of  intense  unilateral  headache,  visual 


MIGRAINE  405 

disturbances,  and  usually  nausea  and  vomiting.  No  pathological 
findings  have  ever  been  reported  for  this  disease. 

Etiology.  Migraine  is  one  of  the  neuroses  which  are  inter- 
changeable in  inheritance.  The  inheritance  of  migraine  usually 
follows  the  female  line.  The  attack  may  begin  as  early  as  the 
first  or  second  year  of  life,  though  the  most  frequent  age  of  onset 
is  ten  to  fifteen  years.  The  attacks  appear  at  intervals  of  a  few 
days  to  a  few  months  until  the  climacteric  has  been  passed,  when 
they  usually  disappear. 

Bony  lesions,  chiefly  of  the  upper  cervical  region,  are  important, 
even  in  hereditary  cases.  Lesions  involving  the  splanchnic  area 
are  often  present.  In  women  in  whom  the  attack  occurs  at  the 
menstrual  period,  lesions  of  the  lumbar  spine,  the  innominates  or 
coccyx  are  frequently  found.  Often  the  attacks  cease  during  preg- 
nancy and  lactation. 

Eye  strain,  hardened  ear  wax,  adenoids,  and  other  causes  of 
peripheral  nerve  irritation  probably  help  in  promoting  the  nervous 
instability.  Patients  themselves  usually  consider  overwork  and  the 
use  of  improper  foods  an  important  factor  in  precipitating  an  attack. 
The  relation  of  migraine  to  epilepsy  has  been  variously  discussed. 
Since  absolutely  nothing  is  known  as  to  the  real  nature  of  either 
migraine  or  epilepsy,  such  discussions  do  not  lead  to  any  very 
useful  results. 

Diagnosis.  Migraine  is  usually  recognized  upon  the  symptoms 
and  history.  The  attacks  begin  most  frequently,  with  visual  dis- 
turbances— flickering  lights  or  flashes,  floating  spots,  dim  vision, 
and  diplopia.  This  is  followed  (sometimes  preceded)  by  various 
sensations  of  vertigo,  dizziness,  nausea,  and  dull  headache.  Very 
sharp  pain,  usually  frontal,  practically  always  unilateral,  gives  the 
name  "hemicrania"  to  the  disease.  This  may  be  so  severe  as  to 
cause  unconsciousness;  it  is  very  obstinate  to  the  usual  analgesic 
drugs,  and  attempts  to  relieve  the  paroxysms  by  these  are  impor- 
tant causes  of  drug  addictions.  The  pain  is  of  a  neuralgic  type; 
sometimes  hot,  sometimes  cold,  applications  give  relief.  After  a 
variable  time,  usually  a  few  hours,  vomiting  becomes  free;  the 
stomach  contents  are  first  vomited,  then  bile;  and  usually  when 
much  bile  has  been  vomited  the  pain  is  relieved,  and  the  patient 
is  left  comfortable  but  very  weak  and  listless.  A  long  sleep,  some- 
times twenty  hours  or  more,  usually  terminates  the  attack  and 
gives  the  necessary  rest.  In  the  intervals  the  patient  is  in  good 
health,  so  far  as  the  migraine  is  concerned. 

Treatment.  During  an  attack  it  is  rarely  possible  to  do  more 
than  secure  relief.  Occasionally  extension  and  careful  correction 
of  muscular  or  bony  lesions  is  possible,  and  this  may  give  marked 
relief.  This  is  especially  true  at  the  onset  of  the  attack.  When 
manipulations  are  painful,  it  is  best  to  postpone  corrective  work 


406  FUNCTIONAL  NEUROSBS 

until  the  acute  attack  has  passed.  The  patient  may  drink  freely 
of  hot  water,  have  an  enema  of  rather  warm  water,  and  go  to  bed 
with  a  hot  water  bottle  at  the  feet  or  over  the  abdomen,  and  an  ice 
bag  or  a  hot  water  bottle  at  the  base  of  the  occiput ;  this  may  avert 
the  attack.  In  patients  of  sedentary  habits,  the  hot  water  and  the 
enema  may  be  followed  by  a  walk  or  some  game  in  the  fresh  air; 
by  a  hot  or  Turkish  bath ;  or  by  massage  of  the  entire  body.  In 
either  case,  at  least  a  day  of  rest  is  necessary,  even  if  the  pain  and 
nausea  are  averted  altogether ;  otherwise  the  next  attack  will  occur 
more  quickly.  It  must  be  remembered  that  the  usual  exciting 
cause  of  an  attack  is  fatigue  of  some  of  the  nerve  centers. 

During  the  intervals,  treatment  must  be  initiated  for  the  pre- 
vention of  the  attacks. 

In  any  case  of  migraine  a  thorough  blood  examination  should 
be  made  for  the  sake  of  determining  the  true  physiological  condi- 
tion of  the  patient.    The  urine  analysis  serves  the  same  purpose. 

Any  effective  treatment  must  be  persisted  in  for  months.  Struc- 
tural perversions  must  be  corrected  and  the  corrections  must  be 
repeated  as  frequently  as  may  be  necessary.  The  diet  must  be 
wholesome,  easily  digested  and  planned  according  to  the  results 
of  the  blood  and  urine  examinations.  Once  carefully  decided  upon 
the  diet  must  be  rigidly  followed.  A  study  of  the  habits  of  the 
patient  is  necessary.  A  careful  regime  must  be  worked  out  and 
this  must  be  followed  religiously.  If  these  directions  are  persist- 
ently followed  even  the  most  evident  of  hereditary  cases  usually 
recover  completely  within  a  year  or  two.  Recovery  is  not  sudden. 
In  the  beginning  the  condition  may  seem  to  be  exaggerated,  the 
attacks  more  severe  and  the  intervals  shorter.  After  one  or  two 
apparent  exacerbations,  the  attacks  become  modified  and  the  inter- 
vals longer,  until  they  should  finally  disappear.  The  person  who 
suffers  from  migraine  should  never  marry  another  who  suffers 
from  migraine,  nor  from  any  other  neurosis. 


OCCUPATIONAL  NEUROSES 

Persons  of  neurotic  temperament  whose  occupations  require 
the  repeated  performance  of  complex  movements  frequently  suflFer 
from  a  cramp  of  the  muscles  concerned  which  is  sometimes  asso- 
ciated with  considerable  pain  w-hen  their  use  is  attempted.  In 
typical  cases  pain  is  not  present  and  the  use  of  the  muscles  in  other 
movements  is  perfectly  normal.  The  only  etiological  factor  is  the 
occurrence  of  fatigue  of  the  nerve  groups  which  control  the  more 
complicated  movements,  especially  of  the  hands.  In  a  number  of 
cases  reported,  bony  lesions  of  the  lower  cervical  and  the  first 
and  second  thoracic  vertebrae  have  been  reported.  The  condition 
of  the  shoulder  and  clavicular  joints  should  be  investigated. 


OCCUPATIONAL  NEUROSES  407 

Writers'  cramp  or  scrivener's  palsy  is  the  most  common  of  these 
neuroses.  Pianists,  violinists,  telegraphers,  seamstresses,  barbers, 
tailors,  shoemakers,  and  cigar  wrappers  are  all  subject  to  these 
muscular  cramps.  Dancers,  men  who  walk  upon  snow  shoes,  and 
skaters  are  sometimes  affected  by  similar  cramp,  affecting  the 
muscles  of  the  legs. 

The  diagnosis  of  writer's  cramp  is  not  often  difficult.  In  some 
cases  agraphia,  ataxia  beginning  in  the  arms,  and  early  paralysis 
agitans  may  be  confused  with  this,  or  some  other  occupational  dis- 
ease. 

The  cramp  which  results  from  the  habitual  and  improper  use 
of  skeletal  muscles  in  maintaining  equilibrium  probably  belongs  in 
this  group.  Lesions  affecting  the  pelvic  girdle  cause  cramp  of  the 
muscles  of  leg;  lesions  affecting  the  shoulder  girdle  cause  cramj> 
of  the  muscles  of  the  forearm ;  lesions  of  the  occiput  cause  cramp 
of  the  muscles  of  the  neck;  lesions  of  the  mandible  cause  cramp  of 
the  muscles  of  mastication,  and  lesions  of  the  thoracic  vertebrae 
may  cause  cramp  of  the  intercostal  muscles  and  the  diaphragm. 
These,  and  other  muscular  cramps,  are  sometimes  confused  with 
neuritis,  as  in  cases  of  sciatica  and  lumbago,  now  generally  recog- 
nized by  orthopedic  surgeons  and  other  physicians  as  being  due 
to  lumbo-sacral  strains,  or  to  subluxations  of  lumbar  vertebrae. 

Treatment.  Rest  is  essential.  The  correction  of  the  bony 
lesions  as  found  facilitates  recovery.  The  left  hand  may  be  used 
instead  of  the  right,  but  the  cramp  soon  affects  this  hand  also. 
For  writers'  cramp  the  typewriter  may  be  advised.  A  bracelet 
which  holds  the  pen  and  is  moved  by  the  forearm  muscles  can  be 
used.  Cramp  is,  however,  apt  to  attack  these  muscles  in  the  course 
of  time.  In  general,  a  change  of  occupation  ultimately  becomes 
necessary. 


CHAPTER  XXXVIII 
NEUROSES  WITH  MOTOR  SYMPTOMS 

EPILEPSY 

(Falling  disease;  seizure;  morbus  sacer) 
A  satisfactory  definition  of  epilepsy  is  very  difficult.  Certainly 
it  is  a  disease  of  the  brain,  of  unknown  cause,  and  characterized 
by  attacks  associated  with  loss  of  consciousness  and  with  more 
or  less  pronounced  motor  phenomena.  There  is  a  tendency  on  the 
part  of  some  authors  to  limit  the  term  epilepsy  to  the  idiopathic 
form,  others  apply  the  term  to  all  typical  seizures  in  which  the 
epileptic  sequence  of  events  is  present. 

Grand  Mai  is  the  term  applied  to  the  ordinary  epileptic  fit  which  shall 
be  described  hereafter^ 

Petit  MaL  has  little  or  no  muscular  action  and  is  characterized  only  by 
a  loss  of  consciousness,  usually  very  short. 

Jacksonian  Epilepsy  is  due  to  a  localized  cortical  lesion.  The 
attacks  always  begin  in  a  certain  limited  area  of  the  body  and  spread  to  neigh- 
boring muscle  groups  until  the  whole  body  is  concerned  in  the  convulsion. 

Epileptic  Equivalent  or  psychic  epilepsy  is  rather  rare.  In  this 
form  the  place  of  the  fit  is  taken  by  what  may  be  called  a  mental  convulsion. 
It  is  really  an  attack  of  more  or  less  violent  insanity. 

"Running  Epilepsy,"  epilepsia  cursoria,  or  procursiva  epilepsia,  are 
terms  applied  to  a  condition  in  which  the  place  of  the  ordinary  convulsion  is 
taken  by  a  sudden  attack  of  violent  running  until  the  patient  is  exhausted.  All 
epileptic  equivalents  are  dementing. 

Myoclonic  Epilepsy  is  a  form  in  which  the  muscles  are  in  a  state 
of  increased  tone  during  the  intervals  of  the  attacks. 

Status  Epilepticus  is  a  state  in  which  the  fits  follow  one  another 
rapidly;  consciousness  may  not  be  regained  in  the  intervals,  and  it  may  be 
impossible  to  count  the  fits.  Occasionally  death  occurs  speedily  from  exhaus- 
tion; occasionally  the  patient  lives  longer  than  seems  in  any  way  possible  in 
this  state,  and  may  even  recover  his  usual  health  after  days  of  apparently  con- 
stant subjection  to  the  epileptic  attacks. 

Nocturnal  epilepsy  occurs  during  the  night  only.  Diurnal  epilepsy 
occurs  only  during  the  day  time. 

S3anptomatic  epilepsy  is  a  symptom  of  recognizable  disease  any- 
where in  the  body,  but  usually  involving  the  brain. 

It  is  very  evident  that  all  epilepsies  are  truly  symptomatic.  Only  because 
we  do  not  know  the  true  cause  of  what  is  ordinarily  called  idiopathic  epilepsy, 
do  we  apply  that  term  to  it. 

Pathology.  Epilepsy  is  preeminently  a  degenerative  disease  of  the  cerebral 
cortex,  though  the  true  nature  of  this  disease  is  as  yet  unknown.  Gliosis  of  the 
horn  of  Ammon  has  been  described.  Various  degenerations  and  atrophies  espe- 
cially affecting  the  external  layer  of  the  cortex  have  been  described.  Small 
hemorrhagic  areas  have  frequently  been  found  in  the  basal  ganglia. 

408 


'      EPILEPSY  409 

Abnormally  small  aorta,  deficient  cerebral  blood  vessels  and  the  congenital 
absence  of  certain  branches  of  the  circle  of  Willis  have  been  considered 
responsible  for  the  condition  through  the  defective  circulation  through  the  brain 
thus  produced. 

Most  epileptics  suffer  from  gastro-intestinal  disorders.  In  most  cases  the 
time  required  for  the  passage  of  food  through  the  alimentary  tube  is  considera- 
bly increased.  The  colon  is  frequently  dilated.  It  is  supposed  that  the  toxic 
materials  absorbed  as  the  result  of  this  slow  peristalsis  may  be  in  part  respon- 
sible for  the  attacks.  The  gastro-intestinal  disorder  is  probably  due  to  the 
underlying  neurosis  which  manifests  itself  also  in  the  epileptic  attacks. 

Etiology.  Heredity  is  a  very  important  factor.  While  epilepsy 
itself  is  not  often  found  in  the  parents,  it  is  very  rare  to  find  a 
case  of  epilepsy  occurring  in  a  family  in  which  no  other  neurosis 
appears.  Hysteria,  migraine,  drug  addiction,  the  alcoholic  habit 
and  other  neuroses  in  the  parents  are  very  frequently  associated 
with  epilepsy  in  the  children.  As  had  been  stated  elsewhere,  the 
inheritance  of  neuroses  in  general  follows  Mendel's  law. 

Alcohol  is  certainly  one  of  the  important  factors.  The  old  idea 
that  the  child  resulting  from  conception  occurring  during  an  alco- 
holic spree  and  especially,  during  the  drunkenness  of  the  father  is 
predisposed  to  epilepsy  is  certainly  based  upon  truth.  This  is  sup- 
ported by  a  study  of  the  children  born  at  a  time  corresponding  to 
various  feast-days  in  certain  localities  in  which  drunkenness  is 
usually  limited  to  such  holiday  periods,  and  by  the  finding  of  a 
number  of  individuals  in  whom  a  single  drunken  intercourse 
resulted  in  conception.  Alcohol  given  children  is  one  cause  of 
epilepsy.  Fortunately  the  indiscriminate  use  of  medicines  con- 
taining alcohol  or  the  opium  derivatives  is  not  at  present  per- 
missible. 

Epilepsies  occurring  during  early  life  may  be  due  to  injury  at 
birth  or  to  the  acute  diseases.  The  cerebral  hemorrhage  produced 
at  birth  has  long  been  recognized  as  a  cause  of  epilepsy  occurring 
sometimes  rather  late  in  childhood.  The  fact  that  injury  to  the 
cervical  spinal  column  may  be  produced  by  abnormal  birth  proc- 
esses, or  by  improper  obstetric  procedures,  is  recognized  by  osteo- 
paths as  being  an  important  factor  in  birth  palsies  as  well  as  in 
epilepsy. 

Falls  and  various  mental  and  physical  shocks  occurring  during 
the  first  few  years  of  life  are  probably  responsible  in  some  cases. 
Here  again  the  presence  of  the  spinal  injuries  must  not  be  for- 
gotten. 

Bony  Lesions.  It  is  very  rare  to  find  a  case  of  idiopathic  epi- 
lepsy in  which  there  is  not  a  lesion  of  the  occiput  or  the  atlas. 
Lesions  of  the  other  cervical  vertebrae,  the  second  to  the  fourth 
thoracic,  and  of  the  ribs  are  also  described  in  this  connection. 

Diagnosis.  It  is  usually  not  difficult  to  make  a  diagnosis  of 
grand  mal.    The  typical  grand  mal  presents  the  following  history: 


410      .  NEUROSES  WITH  MOTOR  SYMPTOMS 

The  patient  may  have  prodromal  symptoms  for  a  few  hours 
to  a  few  days  before  the  attack.  These  usually  include  vague 
uncomfortable  sensations,  some  indigestion,  sometimes  headache 
and  very  often  a  marked  irritability  of  temper;  rarely  a  tendency 
to  somnolence  is  observed.  The  aura  precedes  the  attack  but  a 
few  seconds  or  a  few  minutes.  This  may  be  either  sensory  or 
motor.  The  sensory  aurse  include  olfactory  sensations,  e.  g.,  a 
smell  of  burnt  feathers  or  of  violets;  gustatory,  e.  g.,  a  sweetish 
taste;  auditory,  e.  g.,  ringing  or  crackling  noises;  visual,  e.  g.,  a 
brilliant  red  light,  a  sensation  as  of  flames  or  floating  bright  specks ; 
visceral,  e.  g.,  nausea  or  hunger.  More  commonly  the  aura  con- 
sists of  a  vague,  indescribable  sensation  of  impending  catastrophe. 
The  aura  may  be  sufficiently  prolonged  to  permit  the  epileptic  to 
lie  down  and  thus  lessen  the  danger  of  injury. 

The  convulsion  begins  with  a  tonic  phase,  during  which  all  the 
muscles  of  the  body  are  contracted  and  tense ;  the  face  is  at  first 
pale,  later  red  and  then  purplish.  The  sudden  contraction  of  the 
respiratory  muscles  produces  the  typical  "epileptic  cry."  The 
tonic  phase  is  followed  by  the  clonic,  in  which  the  muscles  alter- 
nately contract  and  relax  in  a  violent  and  often  disastrous  manner. 
The  movements  grow  progressively  less  marked  and  finally  cease. 
The  patient  regains  consciousness  within  a  few  minutes  or  passes 
into  a  deep  sleep,  which  may  be. from  a  few  minutes  to  several 
hours  in  duration. 

During  the  fit  the  tongue  is  often  bitten  so  that  the  blood 
mixes  with  the  saliva.  The  forced  respirations  churn  the  saliva 
into-  a  froth  which  is,  of  course,  sometimes  bloody.  Urine  and 
feces  may  be  voided,  less  commonly  semen  is  expelled.  When  these 
attacks  occur  at  night  the  patient  may  not  be  aware  of  his  condi- 
tion. The  soiled  or  wet  bed  clothing  may  be  the  only  indication 
of  an  attack.  In  children  in  whom  persistent  bed-wetting  occurs 
the  possibility  of  nocturnal  epilepsy  should  be  borne  in  mind. 

In  grand  mal  the  attacks  may  come  at  intervals  of  six  months 
or  even  a  year,  or  they  may  recur  so  often  that  there  is  no  interval 
of  consciousness  between  them.  In  this  condition  the  term  "status 
epilepticus"  is  used. 

The  blood  of  epileptic  patients  is  characterized  by  high  viscidity, 
diminished  coagulation  time,  and  usually  an  increase  in  the  eosin- 
ophile  percentage.  The  hemoglobin  and  the  red  and  white  cell 
counts  are  usually  normal  or  slightly  above.  The  water  in  the 
blood  always  seems  deficient. 

In  the  intervals  between  the  attacks  the  urine  may  be  normal. 
Just  before  the  attack  the  solids  may  be  considerably  diminished. 
After  the  attack  a  small  amount  of  urine,  highly  colored,  usually 
offensive  in  odor,  with  high  specific  gravity  and  heavily  charged 
with  urates  is  voided.  Blood  and  albumin  are  often  present,  and  the 


EPILEPSY  411 

phosphates  may  be  increased  at  this  time.     Occasionally  there  is 
no  change  from  the  normal  in  the  urine. 

The  blood  pressure  is  usually  above  normal  at  all  times  and 
increases  10  to  30  millimeters  before  an  attack. 

Petit  Mai.  The  occurrence  of  short  attacks  of  unconsciousness 
is  not  infrequently  associated  with  grand  mal,  though  petit  mal 
may  exist  alone.  The  attacks  may  occur  at  rather  long  intervals 
as  several  days  apart,  or  they  may  come  rather  frequently.  In  one 
patient  in  the  P.  C.  O.  clinic  the  attacks  came  every  two  minutes 
for  some  days.  The  length  of  the  attacks  varies  from  a  second  or 
even  less  to  several  minutes.  The  patient  is  usually  unaware  that 
anything  has  happened.  He  may  stop  in  the  middle  of  a  word  and 
at  the  termination  of  the  attack  complete  the  word  with  no  idea 
that  his  speech  has  been  at  all  interrupted.  Occasionally  a  slight 
sense  of  dizziness  tells  him  that  he  has  "been  away"  or  "had  a 
spell."  The  relation  between  petit  mal  and  the  epileptic  equiv- 
alent must  not  be  forgotten. 

Psychic  Epilepsy.  The  cases  of  psychic  epilepsy  ipclude  some 
of  the  most  peculiar,  and  some  of  the  most  horrible  of  all  of  the 
crimes  in  history.  From  those  cases  in  which  the  patient,  after  a 
slight  period  of  unconsciousness,  such  as  that  of  petit  mal,  per- 
forms some  clownish  or  illogical  act,  such  as  partially  undressing 
himself,  or  whirling  in  a  circle  while'  he  spits  very  rapidly  in 
every  direction,  to  terrible  murders  of  the  Jack  the  Ripper  type, 
these  patients  display  many  absurd  and  freakish  phenomena.  One 
P.  C.  O.  patient  had  visions  in  which  she  visited  the  home  of  the 
Katzenjammer  Kids.  Occasionally  the  patient  who  has  seemed 
to  be  perfectly  harmless  during  the  attacks  may  suddenly  develop 
a  destructive  mania.  These  patients  are  very  dangerous  if  they 
become  angered  or  frightened. 

Jacksonian  Epilepsy.  This  form  is  invariably  symptomatic. 
The  area  of  the  brain  affected  can  be  rather  strictly  localized  by 
noticing  the  character  of  the  movements  which  begin  the  attack. 
In  this  form  one  certain  muscle  group,  as,  for  example,  the  flexor 
of  the  index  finger,  first  imdergoes  tonic  contraction,  this  is  fol- 
lowed by  flexion  of  the  other  fingers  and  the  forearm,  etc.,  until 
the  whole  body  is  in  tonic  convulsions.  This  is  followed  by  the 
clonic  convulsions  as  in  the  case  of  the  grand  mal  attack.  Some- 
times these  attacks  are  abortive,  and  consciousness  may  not  be 
lost  at  any  time. 

Treatment.  The  treatment  of  epilepsy  must  vary  according  to 
the  conditions  as  found  upon  examination.  In'  idiopathic  epilepsy 
the  upper  cervical  and  occiput  lesions  must  be  corrected.  The  diet 
should  be  almost  exclusively  vegetarian,  with  the  addition  of 
milk  and  the  milk  products  and  eggs.    Meat,  alcohol,  tobacco,  tea, 


412  NEUROSES  WITH  MOTOR  SYMPTOMS 

coffee,  rich  pastry,  are  to  be  refused  absolutely.  Excess  of  starch 
and  of  sugar  should  be  avoided.  Some  epileptics  are  unable  to 
manage  more  than  a  very  small  amount  of  fats.  Fresh  fruits  and 
vegetables,  especially  raw  vegetables,  are  to  be  eaten  very  freely. 
An  increase  in  the  amount  of  water  intake  is  almost  always  neces- 
sary. A  few  weeks  upon  the  exclusive  milk  diet  is  sometimes 
advantageous  in  patients  in  whom  there  is  pronounced  weakness 
and  emaciation. 

The  condition  of  the  gastrointestinal  tract,  especially  the  colon, 
is  important.  Dilatation  of  the  stomach,  constipation,  viscerop- 
tosis must  be  treated  vigorously,  (q.  v.)  H.  W.  Conklin  considers 
the  ascending  colon  and  the  sigmoid  especially  important.  X-ray 
examination  should  be  used  for  determining  the  true  condition  of 
the  intestinal  tract;  this  gives  foundation  for  rational  treatment. 
Enemas  and  manipulations  directed  to  restoring  the  correct  struc- 
tural relations  are  indicated  in  most  epileptics. 

Every  effort  should  be  made  to  remove  possible  sources  of  nerv- 
ous irritation.  The  presence  of  eye  strain  has  been  discussed  pro 
and  con.  There  is  no  doubt  that  epileptic  as  well  as  all  other  persons 
should  be  fitted  with  glasses  when  the  condition  of  the  eyes 
renders  such  a  course  advisable.  Adenoids,  hardened  ear  wax, 
scar  tissue  in  any  part  of  the  body,  intestinal  parasites,  anal 
abnormalities,  adherent  prepuce  or  clitoris,  and  any  other  sources 
of  peripheral  nerve  irritation  should  be  completely  corrected. 
Children  should  be  especially  guarded  from  excitement.  They 
should  not  be  sent  to  the  ordinary  schools,  but  should  receive 
teaching  under  circumstances  that  preclude  the  possibility  of  their 
being  associated  with  other  children  at  the  time  of  an  attack. 
Drugs  are  to  be  avoided.  It  is  true  that  certain  drugs  (bromides) 
commonly  used  diminish  the  force  and  the  frequency  of  the  fits, 
but  these  invariably  increase  the  itiental  deterioration  and  they 
usually  cause  more  or  less  of  gastro-intestinal  and  other  dis- 
turbances. 

The  patient  who  suffers  from  petit  mal  should  be  carefully 
guarded  lest  some  of  the  psychic  phenomena  appear  suddenly.* 
The  patient  with  psychic  epilepsy  should  usually  be  placed  in 
some  institution  where  he  can  be  guarded  from  injury  to  himself 
or  to  others.  In  Jacksonian  epilepsy  and  also  in  certain  other 
types  of  epilepsy  in  which  a  history  of  injury  to  the  skull  is 
secured,  surgical  procedures  are  often  most  helpful.  It  is  neces- 
sary to  make  a  careful  study  of  each  case  in  order  to  decide  upon 
the  location  and  the  nature  of  the  operation  to  be  performed.  The 
help  to  be  secured  from  surgical  interference  depends  greatly  upon 
this  procedure  being  initiated  at  an  early  stage.  It  seems  that 
the  recurrence  of  these  attacks  for  a  considerable  period  of  time 
brings  about  a  degeneration  which  is  more  or  less  widely  spread 
throughout  the  brain  centers. 


EPILEPSY  413 

In  symptomatic  epilepsy,  the  treatment  depends  upon  the  true 
cause  of  the  condition.  Brain  tumors  are  sometimes  operable. 
The  prognosis  and  treatment  in  these  cases  is  always  that  of  the 
underlying  cause. 

The  epileptic  character.  When  epilepsy  begins  early  in  child- 
hood, especially  after  the  attacks  are  frequently  repeated,  the  men- 
tal deterioration  is  speedy  and  marked.  This  is  probably  due  to 
the  fact  that  injury  to  the  cerebral  nerve  cells  is  more  profound 
when  it  acts  upon  them  during  the  stage  of  their  most  rapid  devel- 
opment than  it  is  if  it  acts  upon  them  after  the  development  has 
reached  a  fairly  stable  degree. 

When  the  first  attacks  begin  during  late  childhood  or  during 
puberty,  the  effect  upon  mentality  is  somewhat  less  marked.  In 
these  cases  and  also  in  milder  cases  of  very  early  onset,  we  have 
developed  a  peculiar  personality  which  may  be  due  to  the  effects 
produced  upon  the  brain  or  may  be  due,  at  least  in  part,  to  the 
effects  of  the  treatment  which  epileptics  receive  from  other  chil- 
dren and  from  the  grown  people  with  whom  they  are  associated. 

The  epileptic  is  almost  universally  gloomy,  pessimistic,  ego- 
tistical and  suspicious.  He  may  love  intensely  and  even  with  great 
self-sacrifice.  With  this  he  rarely  trusts  even  those  whom  he 
loves  and  is  almost  invariably  subject  to  furious  jealousy.  Not 
rarely  the  ingenuity  and  the  powers  ordinarily  called  purely  men- 
tal are  excellently  developed  in  epileptics.  This  is  evident  in  the 
fact  that  so  great  a  number  of  epileptic  men  and  women  have  been 
powerful  in  modifying  the  course  of  a  history  of  the  world. 

"Epilepsy,  affecting  centuries  ago  the  greatest  of  the  Caesars,  has  been 
present  as  a  human  affliction  during  all  the  span  of  human  existence.  It  is  rec- 
ognized as  a  condition  resulting  from  effects  upon  the  central  nervous  system, 
due  to  abnormally  constructed  brain  elements,  the  sequence  of  alcoholic  or 
syphilitic  parentage,  to  fright,  injury  to  the  head  or  a  sunstroke,  to  peripheral 
nervous  irritants  such  as  adenoids,  enlarged  tonsils,  adherent  prepuce  or 
lumbricoids  or  to  auto-intoxication  of  a  severe  type. 

"In  this  case  I  have  assigned  its  causes  under  two  heads,  accidental  and 
predisposing,  and  I  have  chosen  to  call  the  accidental  as  follows : 

"1.  Forceps  delivery,  in  which  no  deformity  was  produced  at  the  time,  but 
which  was  undoubtedly  the  cause  of  a  severe  lesion,  occipito-atloid. 

"2.  Fright  early  in  her  sixth  year,  due  to  a  narrow  escape,  while  with 
parents,  from  being  crushed  by  a  train. 

"3.  A  fall  from  a  small  cart  drawn  by  a  boy,  striking  violently  onhtr  head 
on  a  cement  walk,  no  appreciable  damage  to  skull,  this  occurring  two  or  three 
months  before  the  appearance  of  any  trouble. 

"The  predisposing  causes  were  an  oversensitive  nervous  system,  reacting  to 
all  environal  changes,  even  the  most  minor  and  a  tendency  to  gastro-enteritis, 
with  its  concomitant  nervous  influences. 

"The  lesions  presented  are  an  occipito-atloid,  previously  referred  to,  in  which 
the  occiput  on  the  left  is  tightly  jammed  down  upon  the  lateral  mass  of  the 
atlas  and  a  compensating  lateral  axis.  With  these  as  primary  lesions  the  sec- 
ondary lesions  are  alternating  lateral  conditions  at  the  cervico-dorsal  junction 
and  lesions  in  the  lower  thoracic  and  sacro-iliac  regions."^C.  H.  Phinney. 


414  NEUROSES  WITH  MOTOR  SYMPTOMS 

Prognosis.  When  epilepsy  begins  early  in  life,  it  is  usually 
incurable  and  dementing.  When  it  begins  late  in  childhood,  it 
may  be  outgrown  by  about  the  age  of  twenty.  When  its- onset 
shortly  precedes  the  puberty  changes,  it  may  disappear  within  a 
few  years  after  the  puberty  changes  are  completed.  Grand  mal 
has  the  better  outlook ;  petit  mal  is  more  frequently  dementing, 
while  the  psychic  type  is  almost  always  dementing.  Combinations 
of  types  have  the  more  gloomy  prognosis ;'  occasionally,  however, 
a  petit  mal  will  be  followed  by  grand  mal  for  a  few  attacks,  and 
this  be  followed  by  cessation  of  the  attacks.  The  sequence  is 
sometimes  reversed. 

Life  is  not  shortened  by  epilepsy,  until  status  epilepticus  leads 
to  death  from  exhaustion.  The  fits  prevent  patients  from  engaging 
in  much  hard  work ;  rarely  they  may  cause  death  by  accident. 
Epileptics  are  usually  so  egotistical  and  so  selfish  that  they  care 
for  themselves  better  than  normal  persons  .usually  do;  they  may 
outlive  their  generation. 

Recovery  may  be  expected  when  some  removable  cause  can  be 
found  for  the  condition,  provided  suitable  treatment  is  begun  at 
an  early  date,  before  brain  injury  has  supervened. 

ACUTE  CHOREA 

(Infectious  chorea;  Sydenham's  chorea;  St.  Vitus  dance;  St.  Anthony's  dance) 

Acute  chorea  is  an  infectious  disease  of  the  nervous  system, 
characterized  by  the  occurrence  of  awkward,  spasmodic  move- 
ments, especially  of  the  face  and  hands,  and  occurring  chiefly  in 
children  from  5  to  15  years  of  age. 

Pathology.  Very  little  is  known  of  the  brain  changes  in  chorea.  Degen- 
erations in  the  lenticular  nucleus  have  been  reported.  The  heart  is  almost  in- 
variably affected.  Vegetations  are  found  mostly  upon  the  mitral  valve.  Cere- 
bral embolism  affecting  the  smaller  arteries  may  occur. 

Etiology.  The  disease  occurs  most  frequently  in  children  after 
they  begin  to  go  to  school  and  before  puberty.  It  is  rather  rare 
before  the  age  of  7  or  after  20,  though  cases  do  occur  in  very 
young  children  "and  among  old  people.  Although  it  is  probably  an 
infectious  disease,  hereditary  neurotic  taint  is  very  common.  It 
would  seem  that  children  who  descend  from  neurotic  parents  have 
nerve  cells  less  resistent  to  the  action  of  infectious  or  toxic  agents 
than  those  of  normal  ancestry. 

The  ordinary  infectious  diseases  of  childhood  appear  to  be 
responsible  for  a  few  cases.  It  is  more  frequently  associated. with 
rheumatism  or  with  tonsillitis  than  with  any  other  disease.  Heart 
lesions  are  very  common.  The  diagnosis  of  chorea  is  denied  by 
some  authors  in  the  absence  of  evidence  of  cardiac  injury.  The 
place  of  reflex  nerve  irritations  as  a  causative  factor  has  probably 
been  overestimated.     The  infectious  agent  has  not  been  isolated. 


CHRONIC  CHOREA  415 

There  is  some  reason  to  believe  that  it  may  be  identical  with 
that  which  produces  acute  articular  rheumatism. 

Diagnosis.  The  disease  iijay  follow  any  other  contagious  dis- 
ease, rheumatism  or  tonsillitis.  There  is  a  prodromal  period  during 
which  the  child  is  extremely  irritable  and  hard  to  manage,  sleep 
is  disturbed,  bad  dreams  are  frequent,  and  night  terrors  may  occur. 
After  a  few  days,  it  is  noticed  that  he  is  very  awkward  in  his  move- 
ments ;  he  drops  things  which  he  has  in  his  hands,  may  knock 
the  dishes  off  the  table  while  he  is  eating  and  behaves  generally 
in  an  unusually  awkward  manner.  If  he  is  punished,  as  is  too  often 
the  case,  the  condition  grows  more  rapidly  worse,  the  involuntary 
and  spasmodic  character  of  the  movements  then  becomes  evident. 
Silly  grimaces,  twitchings  of  the  facial  muscles  and  of  the  muscles 
around  the  eyes  and  eyelids  are  usually  associated  with  more  or 
less  of  a  shrug  of  the  shoulders.  The  hands  and  feet  and  some- 
times the  whole  body  take  part  in  these  spasms.  The  child  may  be 
so  seriously  affected  as  to  die  from  exhaustion.  He  may  be  unable 
to  swallow  and  respiratory  movements  may  be  irregular.  The 
movements  cease  during  sleep,  but  they  may  prevent  his  being 
able  to  go  to  sleep.  In  most  cases  the  symptoms  are  less  severe 
and  recovery  occurs  in  one  or  two  months.  Those  cases  in  which 
the  fever  is  high,  perhaps  104°,  have  a  worse  prognosis.  The 
diagnosis  is  made  upon  the  symptoms  as  observed. 

Treatment.  The  treatment  of  chorea  depends  upon  securing 
and  maintaining  the  best  possible  circulation  of  the  best  possible 
blood  through  the  central  ^lervous  system.  It  is  equally  advisable 
to  pay  no  attention  to  the  spasmodic  movements  during  the  acute 
stage  of  the  disease.  The  child  should  be  treated  as  gently  and 
kindly  as  possible  during  the  period  of  his  greatest  irritability. 
After  the  disease  has  terminated,  the  movements  , may  persist  as 
habit  spasms.  In  this  case  the  condition  should  be  treated  as  are 
other  habit  spasms  or  tics. 

"The  prognosis  of  simple  chorea  is  good,  nearly  all  cases  get  well  under 
osteopathic  treatment.  Some  few  cannot  be  cured  but  can  be  materially  bene- 
fited. In  those  cases  where  grave  nervous  diseases  are  traceable  in  the  ancestry, 
the  prognosis  is  never  so  good  for  an  absolute  cure." — A.  H.  Zealy. 

CHRONIC  PROGRESSIVE  CHOREA 

(Hereditary  chorea;  degenerative  chorea;  Huntington's  chorea) 

As  the  name  indicates,  this  is  a  degenerative  disease  of  the  brain,  char- 
acterized by  gradually  progressive  choreiform  movements  of  the  voluntary 
muscles,  by  a  progressive  dementia  and  by  its  hereditary  nature.  It  is  rare  in 
the  United  States. 

Etiology.  Heredity  seems  to  be  by  far  the  most  important  cause  of  the 
disease.  In  "choreic  families"  normal  individuals  may  occur.  The  children  of 
these  are  usually  free  from  the  disease,  but  children  who  are  free  from  the 
chorea  and  the  descendants  of  these  are  very  apt  to  suffer  from  epilepsy,  hys- 


416  NEUROSES  WITH  MOTOR  SYMPTOMS 

teria,  idiocy,  the  adolescent  insanities,  or  paranoia.  Its  onset  in  middle  life 
(rarely  before  thirty  or  after  forty-five  years  of  age)  permits  the  transmission 
of  the  disease  in  direct  heredity,  though  not  usually  to  many  children  in  one 
family. 

Pathology.  A  diffuse  meningitis  which  involves  both  the  dura  and  the  pia- 
arachnoid  is  usually  present  Capillary  hemorrhages,  which,  seem  to  be  most 
marked  in  the  corpora  striata,  are  usually  found.  Associated  with  these  are 
various  degenerations  and  atrophies  of  the  cerebral  neurones. 

Diagnosis.  The  symptoms  and  history  give  the  diagnosis.  The  disease 
begins  in  middle  life  with  a  change  of  character,  the  patient  becoming  irritable 
and  unstable.  Peculiar  movements,  jerky  respirations,  changes  in  speech,  appear 
at  first  to  be  the  expression  of  whimsy  or  eccentricity.  The  involuntary  nature 
of  these  movements  soon  becomes  evident.  The  movements  do  not  often  become 
so  severe  as  to  cause  injury,  as  is  the  case  in  infectious  chorea,  but  they  may 
interfere  with  the  patient's  ability  to  earn  a  living.  He  walks  with  his  legs 
wide  apart,  the  arms  hanging  dangling  in  a  jerky  way,  and  the  whole  gait  and 
habit  are  often  clownish.  Indeed  it  is  not  improbable  that  clownishness  orig- 
inated with  such  patients.  The  movements  disappear  in  sleep  and  can  be  vol- 
untarily inhibited  for  a  short  time.  Usually  after  voluntary  inhibition,  they 
recur  with  increased  violence.  After  a  few  months  or  a  few  years,  the  men- 
tality becomes  recognizably  diminished  and  finally  complete  dementia  supervenes. 
Life  does  not  seem  to  be  shortened  by  the  disease  and  the  patient  may  remain 
helpless  and  demented  for  twenty  years  or  more,  unless  some  intercurrent 
malady  terminates  his  pitiable  existence. 

Treatment.  The  treatment  must  be  symptomatic.  A  child  bom  into  a 
family  in  which  this  disease  has  occurred  should  be  kept  in  as  nearly  as  possible 
a  normal  environment,  with  wholesome  surroundings,  good  food  and  prefera- 
bly outdoor  life.  After  the  onset  of  the  disease,  it  is  doubtful  if  anything  can 
be  done  to  prevent  the  ultimate  degeneration.  Intercurrent  maladies  should 
receive  appropriate  attention.  As  soon  as  the  dementia  reaches  a  noticeable 
degree,  the  patient  should  be  sent  to  some  institution  where  he  can  be  made 
comfortable  and  kept  harmless.  Marriage  should  be  prevented,  or  if  members 
of  these  families  are  married,  they  should  remain  childless. 

The  prognosis  is  hopeless  after  the  disease  has  become  evident. 

INFANTILE  CONVULSIONS 

(Eclampsia  infantilis) 
The  occurrence  of  convulsions  resembling  those  of  eclampsia 
and  sometimes  those  of  epilepsy  in  children  during  the  first  or 
second  year  of  life  is  not  at  all  unusual,  especially  in  children  of 
neurotic  inheritance. 

Etiology.  Convulsions  occurring  in  children  may  be  due  to  a 
great  many  different  factors.  These  are  always  either  of  nervous 
or  toxic  origin,  or  both.  Perhaps  the  most  common  causes  are 
intestinal  disturbances  occurring  during  the  eruption  of  the  first 
teeth.  Convulsions  due  to  this  condition  usually  leave  no  serious 
after-effects.  The  presence  of  worms  in  the  intestinal  tract  is  also 
a  frequent  source  of  infantile  eclampsia.  No  doubt  both  the  nerv- 
ous irritation  due  to  the  presence  of  the  worms  and  the  absorption 
of  the  toxic  substances  produced  by  their  metabolism  are  con- 
cerned in  producing  the  convulsions. 


INFANTILE  CONVULSIONS  417 

Acute  nephritis  in  children  may  produce  uremic  convulsions. 
Rachitis  is  frequently  associated  with  convulsions,  which  in  this 
case  are  probably  toxic  in  origin. 

Not  rarely  the  meninges  become  inflamed  in  the  course  of 
the  acute  infectious  diseases  of  childhood,  in  which  convulsions 
resembling  those  of  ordinary  meningitis  are  likely  to  occur.  High 
fever  associated  with  the  acute  infectious  diseases,  or  with  gastro- 
intestinal diseases,  may  produce  convulsions. 

Emotional  storms  in  neurotic  children  frequently  cause  ex- 
tremely severe  convulsions,  and  these  may  be  associated  with 
slight  capillary  hemorrhages  into  the  brain  substance.  Children 
who  suffer  from  convulsions  upon  apparently  trivial  excitement  or 
emotional  shocks  are  very  likely  to  grow  up  into  hysterical  or 
neurasthenic  adults. 

Sometimes  the  fits  which  appear  to  be  infantile  convulsions 
recur  through  childhood  as  true  epilepsy.  In  such  cases  it  is  prob- 
able that  what  appeared  to  be  infantile  convulsions  due  to  gastro- 
intestinal disorders,  was  merely  epilepsy  occurring  at  that  time. 

Convulsive  attacks  in  children  may  be  due  to  organic  brain 
lesion,  brain  tumors,  rarely  hydrocephalus,  brain  tuberculosis, 
inherited  syphilis;  or  the  postponed  effects  of  cerebral  hem- 
orrhages caused  at  birth  may  be  responsible  for  one  or  several 
convulsions  occurring  duTing  the  first  few  years  of  life.  All  of 
these  extremely  varied  etiological  factors  indicate  that  infantile 
convulsions,  as  well  as  epilepsy,  must  be  considered  a  symptom  of 
some  underlying  disease. 

Pathology.  The  pathology  differs  according  to  the  various  causative 
factors.  Various  degenerations  of  the  motor  cortex  and  the  basal  ganglia 
have  been  reported.  Capillary  hemorrhages  in  the  meninges  and  in  the  brain  are 
sometimes  present.  The  lesions  of  rickets  may  be  found.  The  convulsions 
themselves  are  probably  responsible  for  minute  hemorrhages  in  the  brain  and 
meninges  and  for  the  chromatolysis  and  vacuolization  of  the  motor  neurons 
of  the  brain  and  cord. 

Diagnosis.  The  diagnosis  of  infantile  convulsions  is  easy,  for 
the  very  fact  of  the  convulsive  spasm  is  rather  typical.  A  child 
which  has  been  more  or  less  ailing  for  a  few  days  becomes  pale, 
seems  to  lose  consciousness,  the  muscles  undergo  sudden  stiffness, 
and  the  legs,  arms  and  back  become  straight;  the  respiratory 
muscles  are  contracted,  the  breath  is  held ;  lips  are  blue,  face  is 
very  pale,  and  this  terrifying  appearance  remains  for  a  few  sec- 
onds or  a  few  minutes,  the  breath  is  caught,  face  flushes,  the  child 
screams,  the  muscles  relax,  and  the  attack  is  over,  or  it  may  be 
immediately  succeeded  by  another  similar  attack.  Occasionally 
the  muscles  remain  contracted,  respiration  is  difficult,  and  pallor 
is  marked  for  some  hours. 

The  diagnosis  of  the  underlying  cause  of  the  convulsion  is 
sometimes  very  difficult.    When  the  spasm  is  due  to  gastro-intes- 


418  NEUROSES  WITH  MOTOR  SYMPTOMS 

tinal  symptoms,  the  history  of  previous  gastro-intestinal  disease 
or  of  the  eating  of  improper  foods  may  help  in  the  diagnosis.  The 
stomach  tube  or  enema  may  bring  absolute  proof  of  the  cause  of 
the  disturbance.  The  recognition  of  worms  (q.  v.)  in  the  intestine 
is  sometimes  difficult.  Kidney  disease  should  be  suspected  when 
there  has  been  edema,  or  when  there  is  a  urinary  odor  about  the 
child.  Urinalysis  is  always  indicated.  Diagnosis  of  the  acute 
infectious  diseases,  rickets  or  meningitis  can  be  made  by  applying 
the  tests  usual  in  these  conditions.  Usually  there  is  something  in 
the  symptoms  which  suggests  these  diseases.  The  organic  brain 
lesion  may  present  considerable  difficulty  in  diagnosis.  Examina- 
tion of  the  fundus  of  the  eye  should  never  be  neglected  in  children 
who  are  subject  to  convulsions  without  recognizable  cause.  Blood 
examination  may  indicate  the  correct  diagnosis. 

Treatment.  The  treatment  of  the  convulsion  itself  is  rarely 
difficult.  The  old-fashioned  process  of  putting  the  child  into 
warm  mustard  water  is  probably  the  best  thing  the  mother  can  do. 
Gentle  and  prolonged  extension  of  the  spine  is  good.  Raising  the 
ribs  in  the  movements  of  artificial  respiration  frequently  brings 
the  convulsion  to  a  sudden  termination.  If  gastric  disturbances 
are  present,  it  may  be  necessary  to  use  the  stomach  tube  as  soon 
as  the  relaxation  of  the  muscles  permits.  Dilatation  of  the  anal 
sphincter  may  terminate  the  attack,  and  is  indicated  when  there 
is  reason  to  believe  that  worms  or  other  anal  irritations  are  pres- 
ent. When  the  convulsion  is  caused  by  adherent  prepuce  or 
clitoris,  the  relief  of  this  tension  may  relieve  the  spasm.  In 
uremic  convulsions  the  treatment  as  outlined  for  uremia  in  gen- 
eral should  be  employed. 

The  convulsions  due  to  brain  lesion  usually  do  not  yield  to 
any  ordinary  therapeutic  methods.  In  these  cases  or  in  severe 
convulsions  due  to  any  other  cause,  the  inhalation  of  chloroform 
may  be  necessary.  A  very  few  drops  sprinkled  upon  a  handker- 
chief and  held  in  front  of  the  child's  nose  is  usually  sufficient.  It 
is  not  advisable  to  permit  chloroform  to  be  given  by  any  member 
of  the  family  as  a  general  thing.  Not  only  is  there  danger  of 
sudden  disastrous  results  from  overuse  or  improper  use  of  the 
chloroform,  but  this  poison  itself  sometimes  has  a  very  serious 
eflfect  upon  the  liver. 

For  the  treatment  of  the  cause  of  the  convulsion  it  is  neces- 
sary to  consider  the  etiology.  The  underlying  neurosis  is  usually 
best  met  by  securing  increased  nutrition  and  better  hygiene  and 
education  for  the  child.  Emotional  disturbances  and  especially 
ill-judged  attempts  at  discipline  by  nervous  and  erratic  parents 
must  be  carefully  avoided.  Education  must  be  secured  by  the 
use  of  firm  and  yet  gentle  measures,  always  avoiding  emotional 
storms.     Organic  brain  lesions  and  certain  bodily  conditions  may 


TICS,  419 

best  be  removed  by  suitable  surgical  measures.  Proper  diet, 
proper  habits  of  living,  the  correction  of  bony  lesions  as  found 
upon  examination,  together  with  the  treatment  adapted  to  such 
other  abnormalities  as  may  be  found  on  examination  should 
result  in  recovery  in  by  far  the  greater  number  of  these  cases. 

Prognosis.  In  any  case  of  infantile  convulsions,  a  somewhat 
guarded  prognosis  should  be  given.  While  it  is  true  that  by  far 
the  larger  number  of  these  cases  recover  completely  with  no  ill 
after-effects,  yet  it  is  impossible  in  any  given  child  to  say  definitely 
whether  this  will  be  true  in  his  case.  The  possibility  that  the 
convulsion  may  be  the  first  of  a  series  of  epileptic  attacks,  or  that 
it  may  be  the  symptom  of  some  unrecognized  nervous  disease^ 
must  never  be  forgotten. 

TICS 

(Habit  chorea;  habit  spasm;  motor  tic;  palmus) 
A  tic  is  an  involuntary  movement  occurring  in  neurotic  indi- 
viduals as  the  result  of  some  voluntary  movement  first  performed 
under  the  influence  of  a  morbid  physical  or  mental  condition. 

Etiology.  Probably  a  neurotic  constitution  is  necessary  to 
the  formation  of  any  tic.  Morbid  physical  conditions  affecting 
the  activity  of  the  nervous  system  in  pain  certainly  act  as  pre- 
disposing factors.  Tics  may  originate  from  habit  as  in  the  case 
of  a  limp  which  persists  after  a  painful  injury  to  the  foot  or  it 
may  originate  from  some  violent  emotional  state,  as  the  blinking 
of  the  eyes  after  the  sig^t  of  some  terrifying  object,  or  it  may 
represent  some  of  the  repressed  emotions,  such  as  have  been  so 
strongly  emphasized  by  the  Freudian  school,  as  in  certain  forms 
of  tremor  of  the  right  hand. 

Children  are  especially  apt  to  have  tics  develop  as  the  result 
of  imitation  of  other  children,  a  child"  with  chorea,  for  example, 
may  set  the  example  of  choreiform  movements  to  his  playmates. 

Diagnosis.  It  is  sometimes  rather  difficult  to  decide  whether 
any  given  movement  is  a  tic  or  spasm.  The  tic  can  usually  be 
imitated  exactly,  the  spasm  cannot.  The  tic  disappears  with 
education,  either  with  or  without  some  psychoanalysis.  The 
origin  of  the  tic  is  in  some  volitional  movement,  spasm  makes  its 
own  appearance.  The  tic  may  involve  almost  any  of  the  volun- 
tary muscles.  Functional  wry-neck,  blepharospasm,  grimaces, 
peculiar  movements  of  the  tongue  and  the  mouth,  shrugging  of 
the  shoulders  and  many  awkward  movements  of  the  hands  and 
fingers  are  forms  of  tic.  Certain  types  of  stuttering  and  stammer- 
ing speech  are  tics. 

Treatment.  Reeducation  is  by  far  the  most  important  factor 
in  treatment.     In  order  to  secure  cure,  the  patient  must  imitate 


420  NEUROSES  WITH  MOTOR  SYMPTOMS 

his  involuntary  movement  until  he  can  perform  it  voluntarily. 
If  the  tic  includes  speech  disturbance,  he  must  imitate  his  stutter- 
ing performance,  or  imitate  very  carefully  whatever  sounds  he 
may  have  been  making.  One  can  refrain  from  doing  only  those 
acts  which  he  is  capable  of  performing.  As  soon  as  he  has  learned 
to  perform  the  action  represented  by  his  tic  exactly,  he  is  able  to 
refrain  from  performing  that  action.  Usually  the  very  learning 
to  do  the  act  results  in  its  inhibition.  When  there  is  reason  to 
suppose  that  an  emotional  shock  or  some  repressed  complexes  are 
concerned  in  the  etiology  of  any  particular  tic,  some  modification 
of  the  methods  of  psychoanalysis  may  be  employed. 


GENERAL  TIC 

General  tic  is  a  disease  which  is  characterized  by  the  occur- 
rence of  extremely  complicated  movements,  with  or  without 
speech  disturbances.  The  mentality  is  not  affected,  though  im- 
perative ideas  and  obsessions  are  not  rare. 

Etiology.  No  cause  is  known  for  the  occurrence  of  the  disease, 
other  than  that  it  is  most  apt  to  occur  in  neurotic  individuals 
or  in  those  of  neurotic  heredity.  It  occurs  in  late  childhood, 
frequently  just  before  the  onset  of  adolescence,  and  both  sexes  are 
about  equally  affected.  The  disease  generally  begins  in  some  of 
the  eye  muscles,  especially  orbicularis  palpebrae.  Uncontrollable 
winking  is  the  most  frequent  first  symptom.  Various  facial 
spasms  follow  and  then  other  muscles  take  part  in  the  convulsive 
reaction.  Various  cries,  sometimes  imitating  the  crow  of  the 
cock,  or  the  bark  of  a  dog,  or  the  sudden  and  explosive  speaking  of 
certain  words  (coprolalia,  echolalia,  etc.)  may  occur.  Echoftinesis 
or  the  tendency  to  imitate  any  movement  which  he  sees  others 
perform  may  result  in  considerable  mental  disturbance.  The  men- 
tality is  not  affected  and  the  patient  usually  feels  his  lack  of  self- 
control  most  keenly. 

Diagnosis.  The  diagnosis  rests  upon  the  symptoms  as  enume- 
rated and  is  usually  not  difficult. 

Treatment.  The  treatment  is  based  upon  securing  the  best 
possible  circulation  of  the  best  possible  blood  through  the  brain 
and  cord.     Rest  and  ordinary  good  hygiene  are  important. 

Prognosis.  The  prognosis  is  very  bad  for  recovery.  The  most 
that  can  be  hoped  for  is  to  delay  the  further  progress  of  the  dis- 
ease to  some  extent.  Life  is  not  shortened  by  the  disease.  Indeed 
such  patients  are  apt  to  live  longer  than  norma-1  people,  because 
they  are,  by  their  infirmity,  protected  from  the  ordinary  infections 
and  accidents  of  normal  life. 


PARAMYOCLONUS  MULTIPLEX  All 

PARAMYOCLONUS  MULTIPLEX 

(Myoclonus  multiplex;  including  also  myokymia  fibrillary;  chorea  of  Mouvine; 

myoclonus  fibrillaris;  multiplex  of  Kny;  electric  chorea  of  Dubini; 

Bergeron,  and  Henoch) 

This  is  a  disease  of  unknown  etiology  and  pathology,  characterized  by  sud- 
den spasmodic  contractions  of  muscles  which  are  rapid  and  do  not  produce 
movements  of  the  limbs  or  body. 

Etiology.  The  disease  occurs  in  families  in  which  the  hereditary  neuroses 
occasionally  appear.  Emotional  disturbances,  especially  fright,  are  frequently 
given  as  the  cause  by  the  patient  or  his  family.  Similar  spasmodic  contractions 
are  sometimes  associated  with  idiocy. 

Diagnosis.  This  rests  upon  the  lightning-like  character  of  the^  contrac- 
tions, which  greatly  resemble  the  effects  produced  upon  a  muscle  by  stimulation 
with  the  electric  current.  The  movements  may  be  very  frequently  up  to 
100  each  minute.  There  are  no  symptoms  of  organic  nervous  disease  and  no 
changes  in  mentality,  the  tendon  reflexes  are  increased  but  slightly  and  no 
changes  in  the  electrical  reactions  have  been  reported.  The  disease  may  be 
confused  with  hysteria  or  with  infectious  chorea. 

Electric  Chorea  of  Dubini  is  endemic  in  Northern  Italy,  and 
is  found  in  this  country  only  among  immigrants.  This  form  begins  with  pain 
in  the  neck.  The  muscular  contractions  are  marked  and  may  be  painful.  In 
a  few  days  to  a  few  months  coma  appears  and  death  results.  It  is  almost 
invariably  fatal  within  a  few  months.  In  this  form  meningeal  congestion  is 
found,  and  it  is  often  associated  with  inflammatory  diseases  in  the  lungs  or 
sometimes  in  other  viscera. 

Henoch's  Chorea  may  be  merely  a  subtype  of  infectious  chorea. 
It  appears  in  infants  or  children  and  becomes  chronic  rather  than  self-limited, 
as  is  usual  in  the  infectious  type.    It  may  disappear  at  puberty. 

Bergeron's  Chorea  appears  in  poorly  nourished  and  anemic  chil- 
dren.    The  progress  is  about  that  of  Henoch's  Chorea. 

Tetanic  Chorea  is  a  peculiar  form  of  chorea  in  which  the  move- 
ments are  made  slowly  and  somewhat  strenuously,  as  is  evidenced  by  the 
expression  tetanic.  This  disease  is  rather  rare  and  is  associated  with  cirrhosis 
of  the  liver  in  every  case  so  far  reported. 

Nodding  Spasms  of  Infants.  This  is  rarely  found  in  this  country.  A  few 
hours  or  a  few  days  after  birth  nodding  movements  occur.  These  disappear 
during  sleep  and  do  not  seem  to  cause  the  infant  any  particular  discomfort. 
They  may  persist  for  a  few  months  or  they  may  last  until  the  child  begins 
to  walk  when  they  gradually  disappear. 

Treatment,  In  all  of  these  cases  the  treatment  must  be  planned  towards 
securing  the  best  possible  circulation  of  the  best  possible  blood  through  the 
entire  central  nervous  system.  The  prognosis  is  implied  in  the  description  of 
the  disease  already  given. 

PARALYSIS  AGITANS 

(Parkinson's  disease;  jerking  palsy) 

Paralysis  agitans  is  a  disease  of  late  middle  life  which  is  char- 
acterized by  a  treinbling  of  the  muscles,  increase  in  muscular 
tone  and  progressive  weakness. 


422  NEUROSES  WITH  MOTOR  SYMPTOMS 

Etiology.  Almost  nothing  is  known  of  the  cause  of  the  disease. 
There  is  no  reason  to  suspect  any  hereditary  taint.  The  disease 
is  likely  to  occur  after  a  fall,  hard  work,  fright  or  excitement,  or 
after  the  occurrence  of  some  infectious  disease.  Since  all  of  these 
factors  are  very  common,  while  the  disease  itself  is  rather  rare,  it 
is  evident  that  these  factors  alone  are  not  sufficient  to  account  for 
its  etiology.  Bony  lesions  of  the  cervical  and  upper  thoracic 
region  are  almost  universally  present. 

Pathology.  Almost  nothing  is  known  of  the  pathology  of  paralysis 
agitans.  Atrophy  of  the  cells  in  the  motor  cortex,  gliosis  in  the  spinal  centers, 
and  overgrowth  of  neuroglia  around  the  spinal  arteries  have  been  described. 
All  these  changes  are  found  in  senility,  whether  paralysis  agitans  had  been  pres- 
ent or  not.  Similar  conditions  have  been  induced  in  animals  by  the  removal  of 
the  parathyroid  glands,  and  there  is  a  certain  amount  of  evidence  looking  to 
the  thyroids  and  the  parathyroids  as  being  concerned  in  this  disease. 

Diagnosis.  The  diagnosis  is  made  upon  the  symptoms.  The 
disease  begins  in  the  fingers,  then  extends  to  the  muscles  of  the 
arms,  the  neck  and  other  groups.  The  increased  tone  of  the 
muscles  gives  a  certain  stiffness  to  all  voluntary  movements.  This 
increase  in  tone  is  not  limited  to  the  trembling  muscles,  but 
usually  involves  practically  the  entire  body.  The  face  assumes 
a  set  mask-like  expression;  all  ordinary  movements  are  performed 
in  a  stiff  and  awkward  manner;  the  gait  is  characteristic — the  pa- 
tient finds  difficulty  in  getting  started  to  walking  and  his  shoulders 
bend  forward,  his  arms  hang  stiffly  and  he  walks  as  if  he  were 
being  pushed  from  behind.  This  effect  is  emphasized  by  the  fact 
that  the  change  in  the  center  of  gravity  of  the  body  makes  it 
necessary  for  him  to  walk  more  briskly.  The  gait  resembles  a 
sort  of  slow  trot. 

The  mental  processes  usually  are  delayed,  increased  reaction 
time  sometimes  is  evident  even  without  the  use  of  any  particular 
tests.  The  simplest  question  may  have  its  answer  delayed  for 
some  seconds  or  minutes.  The  mentality  is  usually  unaffected, 
although  a  recognition  of  his  condition  usually  causes  him  to 
be  more  or  less  depressed.  One  patient  in  the  P.  C.  O.  clinic  was 
so  affected  in  this  way  that  he  committed  suicide.  Usually, 
however,  the  depression  is  much  less  marked. 

Treatment.  The  correction  of  the  bony  lesions  as  found  or  the 
use  of  movements  which  increase  the  mobility  of  the  spinal  column 
in  a  general  way  usually  lessen  the  tremor  or  cause  it  to  disappear 
altogether  for  some  hours.  The  progress  of  the  disease  is  some- 
what diminished,  apparently,  by  such  treatment.  A  few  cases  in 
the  incipient  stage  have  been  reported  cured. 

The  affected  muscles  should  be  kept  at  rest.  Passive  move- 
ments and  massage  are  somewhat  beneficial.  Cold  usually  in- 
creases the  stiffness  and  the  tremor.     Therefore,  patients  should 


PARALYSIS  AGITANS  423 

be  sent  to  a  warm  climate  if  possible.  A  long  continued  warm 
or  neutral  bath  frequently  relieves  the  trembling  for  some  hours. 
Rest  of  body  and  mind  are  very  important.  Members  of  the  fam- 
ily must  be  warned  against  any  display  of  impatience  when  the 
patient  is  slow  in  answering  questions,  or  when  he  fails  to  under- 
stand as  readily  as  had  been  his  custom. 

The  neck  must  receive  careful  attention.  Contracted  muscles 
may  interfere  with  cerebral  drainage,  or  with  the  circulation  or 
innervation  of  the  thyroid  or  parathyroid  glands.  This  treatment 
relieves  the  melancholy  tendencies  in  many  cases.  The  lower 
thoracic  region,  especially  the  eleventh  and  twelfth  thoracic  ver- 
tebrae and  ribs  usually  require  correction.  Normal  condition  of 
the  liver  and  kidneys  may  prevent  adverse  toxic  influences  upon 
the  muscles. 

Prognosis.  The  disease  does  not  apparently  interfere  with  the 
general  health,  except  as  the  stiffness  may  be  responsible  for  some 
accident.  Recovery  is  not  to  be  expected  in  typical,  well-devel- 
oped cases. 


CHAPTER  XXXIX 
DISEASES  OF  THE  PERIPHERAL  NERVES 

GENERAL  DISCUSSION 

The  symptoms  produced  by  abnormal  states  affecting  the 
peripheral  nerves  depends  upon  the  structure  of  the  nerve  trunks 
and  their  central  and  sympathetic  relations.  The  nerve  fibers 
which  make  up  a  nerve  trunk  are  three  in  origin  and  function. 
The  motor  nerve  fibers  arise  from  the  nerve  cells  in  the  anterior 
horns  of  the  spinal  cord;  the  sensory  fibers  arise  from  the  cells  in 
the  sensory  ganglia  in  the  intervertebral  foramina,  and  related 
cerebral  ganglia;  the  vasomotor  and  secretory  and  visceromotor 
fibers  arise  in  sympathetic  ganglia,  situated  in  various  parts  of  the 
body.  The  motor  and  sensory  nerve  fibers  (except  the  olfactory) 
are  enclosed  in  a  fatty  sheath,  called  the  medullary  sheath,  or 
white  substance  of  Schwann;  this  is  structureless  and  its  exist- 
ence depends  in  some  way  upon  the  functioning  of  the  nerve  fiber. 
Around  the  medullary  sheath  is  a  very  delicate  membrane  of  con- 
nective tissue,  the  neurilemma.  The  sympathetic  fibers,  which 
lack  the  medullary  sheath,  are  surrounded  by  the  neurilemma,  as 
are  the  cerebrospinal  fibers.  These  various  fibers  are  bound  into 
bundles,  which  are  loosely  supported  and  permeated  by  connective 
tissues.  Blood  and  lymph  vessels  for  the  nutrition  of  the  nerve 
trunks  are  carried  in  the  connective  tissues;  these  receive  nerves 
for  their  control.  Sensory  nerves  also  are  distributed  to  the  nerve 
trunks. 

Abnormal  conditions  which  affect  the  vasomotor  and  sensory 
nerves  of  the  nerve  trunks,  nervi  nervorum — may  cause  severe 
pain  in  the  nerves  themselves,  without  causing  any  interference 
with  the  structures  innervated  by  the  nerves  affected  (neuralgia)  ; 
irritating  substances  in  the  circulating  blood  may  affect  either  the' 
nerve  fibers  within  the  nerve  trunks  (toxic  neuritis)  ;  or  may  affect 
more  seriously  the  nervi  nervorum  (toxic  neuralgia)  ;  pathogenic 
bacteria  affecting  the  nerve  trunk  usually  affect  all  its  structure 
(neuritis  due  to  the  infectious  diseases)  ;  abnormal  structural  rela- 
tions, tumors,  fragments  of  bone,  callus,  gummata,  etc.,  affect  first 
the  nervi  nervorum,  causing  what  is  usually  called  neuralgia,  later, 
affect  the  ultimate  fibers,  and  pressure  neuritis  results. 

It  seems  fairly  evident  that  the  vasomotor  control  of  the  nerve 
trunks  is  a  function  of  the  spinal  vasomotor  centers  in  the  lateral 
horns  of  the  cord,  and  thus  is  subject  to  reflex  disturbances,  as 
are  other  tissues  of  the  body.  The  neuralgia  which  results  from 
cold,  or  from  visceral  disease,  is  thus  explained.     Bony  lesions 

424 


NEURALGIA  425 

may  cause  disturbed  vasomotor  control  of  the  nerve  trunk  in  this 
w^ay;  the  slight  congestion  may  persist  and  ultimately  a  true 
neuritis  result. 

It  is  probable  that  much  of  the  pain  caused  by  visceral  disease 
is  due  to  neuralgia  of  the  somatic  nerves,  most  closely  related  to 
the  affected  viscera  in  the  spinal  or  lower  cerebral  centers.  Abnor- 
mal irritability  in  any  sensory  center  is  apt  to  be  referred  in  con- 
sciousness to  those  peripheral  areas  most  frequently  the  origin  of 
stimulation;  for  this  reason  sensations  arising  from  visceral  dis- 
ease are  often  referred  to  the  skin,  joints  and  muscles,  innervated 
from  the  same  segments  (referred  or  reflex  neuralgia).  Here 
again  the  effect  of  bony  lesions  may  be  found;  the  disturbed 
sensory  impulses  due  to  the  tension  on  the  articular  nerve  end- 
ings may  be  referred  to  the  peripheral  areas.  The  hypersensitive- 
ness  associated  with  bony  lesions  is  often  of  this  type. 

The  peripheral  effects  produced  by  neuritis  and  neuralgia,  such 
as  paresthesias,  anesthesias,  lesions  of  the  skin,  disturbances  of 
secretion  and  of  the  growth  of  hair,  paralysis,  muscular  hyperten- 
sion and  muscular  atony,  are  undoubtedly  due,  in  some  cases  to 
the  structural  injury  to  the  nerve  trunk  itself,  and  in  some  cases 
to  the  disturbed  action  of  the  spinal  or  lower  cerebral  nerve  cen- 
ters; this  may  in  turn  be  due  directly  to  the  neuralgia  itself,  or, 
more  frequently,  due  to  the  same  underlying  conditions  which 
cause  the  neuralgia. 

From  what  has  been  said  it  is  evident  that  a  diseased  condition 
which  is,  at  first  a  neuralgia,  may  so  affect  the  circulation  through 
the  nerve  trunk  and  perhaps  the  trophic  relations  of  the  fibers, 
that  a  true  neuritis  is  produced. 

NEURALGIA 

Neuralgia  is  a  painful  disease  of  the  nerve  trunks  or  their 
distribution,  characterized  by  varying  intensity  and  location,  and 
by  the  absence  of  any  constant  recognizable  anatomic  changes. 

Etiology.  It  is  due  to  variations  in  the  circulation  through  the 
nerve  trunk,  or  to  the  presence  of  irritant  toxins  in  the  circulating 
blood,  acting  upon  the  sensory  nerve  endings.  The  first  factor 
may  be  reflex,  as  in  the  facial  neuralgia  due  to  decayed  teeth,  eye 
strain,  etc.,  the  sciatica  due  to  rectal  or  other  pelvic  disease,  and 
to  those  neuralgias  due  to  bony  lesions  anywhere.  The  second 
factor  may  be  due  to  autointoxication  of  any  kind,  including  copre- 
mia ;  to  inorganic  poisons,  as  lead,  arsenic,  or  mercury,  or  to 
organic  poisons  taken  as  drugs  or  with  foods,  as  alcohol,  tobacco, 
tea,  coffee,  or  meat  used  excessively.  Generally,  poor  nutrition 
causes  neuralgia,  both  from  the  lack  of  efficient  circulation,  and 
from  the  products  of  metabolism,  which  are  usually  retained  more 
or  less  extensively  in  starvation.    Early  stages  of  pressure  neuritis 


426  •    THB  PERIPHERAL  NERVES 

are  often  wrongly  diagnosed  as  neuralgia.  Any  cause  of  neuralgia, 
persisting,  may  ultimately  cause  a  structural  change  in  the  nerve 
trunk,  often  inflammatory,  and  thus  terminate  in  a  true  neuritis. 

Diagnosis.  The  symptoms  are  fairly  pathognomonic.  The  at- 
tacks begin  as  paresthesias  which  become  sharply  painful;  sen- 
sations of  heat,  cold,  boring,  cutting,  grinding,  pricking,  stabbing, 
are  variously  described.  Twitchings,  like  those  produced  by  elec- 
tricity, are  frequent.  Muscular  contractions,  most  pronounced  in 
the  deep  spinal  layers  of  the  segment  of  origin  of  the  affected 
nerve,  are  constant.  Vasomotor  changes — pallor  or  flushing 
— of  the  area  of  distribution  of  the  affected  nerve  may  occur. 
Trophic  disorders  may  include  dermatitis  and  eczematous  eruption, 
urticaria,  and  others  less  frequently. 

Neuralgia  may  be  confused  with  neuritis ;  diseases  of  the  spinal 
cord,  especially  myelitis  and  tabes;  meningitis,  rheumatism;  and 
disease  of  the  brain. 

Treatment.  The  treatment  includes  the  recognition  and  removal 
of  the  cause  in  each  individual.  In  any  case  the  pain  itself 
initiates  reflex  contraction  of  the  muscles  innervated  by  the  same 
spinal  segment  or  medullary  center.  These  muscular  contractions 
tend  to  cause  slight  congestion  of  the  nerve  trunk  and  to  increase 
the  neuralgic  pain;  the  relief  of  these  muscular  contractions,  and. 
of  whatever  structural  perversions  these  may  have  caused,  is  an 
important  factor  in  the  treatment  of  any  case  of  neuralgia  however 
produced.  Neuralgia  is  almost  always  associated  with  poor  nutri- 
tion ;  though  the  patient  may  be  obese. 

Prognosis.  With  such  modifications  in  the  diet  and  hygiene 
as  may  be  indicated  in  each  case  and  the  relief  of  structural  per- 
versions nearly  any  case  of  neuralgia  will  disappear.  Those  cases 
due  to  pressure,  by  tumors,  broken  bones,  scar  tissue,  usually 
require  surgical  relief;  in  the  case  of  the  callus  around  a  broken 
bone,  it  may  be  necessary  to  use  merely  palliative  measures  until 
the  bone  is  healed,  when  the  pain  disappears;  or  persists  until 
surgical  relief  is  compelled.  In  such  cases,  massage,  hot  and  cold 
applications  may  give  relief. 

Facial  Neuralgia.  (Tic  doloreaux,  frontal  neuralgia.)  Neu- 
ralgia often  affects  some  of  the  branches  of  the  fifth  cranial  nerve, 
with  perhaps  greater  suffering  than  in  any  other  location.  The 
pain  is  often  of  a  twitching  nature,  superimposed  upon  a  dull, 
unendurable  aching. 

Lesions  of  the  upper  cervical  and  upper  thoracic  vertebrae,  and 
of  the  mandible,  are  important  factors  in  etiology  and  in  treat- 
ment. Diseases  of  the  teeth,  especially  at  the  roots,  antrum 
disease ;  nasal  polyps ;  middle  ear  disease ;  and  probably  eye-strain, 
are  the  most  frequent  causes  of  the  milder  forms;  these  usually 


NEURALGIA  427 

yield  to  the  treatment  already  mentioned.  Occasionally  the  neu- 
ralgia is  due  to  a  degenerative  process  occurring  in  the  Gasserion 
ganglion,  which  an  turn  may  be  the  result  of  a  syphilitic  pachymen- 
ingitis, or  of  arteriosclerosis,  and  relief  is  secured  with  great  diffi- 
culty. A  lowering  of  the  blood  pressure  (see  arteriosclerosis)  may 
afford  relief  in  some  cases.  Surgical  extirpation  of  the  ganglion  is  a 
serious  operation,  but  may  be  inevitable.  Destruction  of  the 
affected  nerve  trunk — except  the  ophthalmic — may  be  secured  by 
injections  of  alcohol  into  the  nerve  itself.  Surgery  is  only  to  be 
recommended  after  other  means  fail,  and  the  pain  remains  unen- 
durably  severe.  Sometimes  it  recurs  after  surgery.  Not  rarely 
nothing  gives  relief  until  the  death  of  the  patient. 

Occipital  Neuralgia  is  usually  due  to  carrying  heavy  loads 
upon  the  head  or  shoulders,  or  to  falls;  it  is  practically  always 
associated  with  lesions  of  the  occiput,  atlas  or  axis.  Rarely  spon- 
dylitis is  found  as  high  as  this  area.  In  most  cases,  correction  of 
the  lesions  as  found  gives  speedy  relief;  the  pain  may  recur  when 
the  lesions  recur,  but  persistent  treatment  should  result  in  per- 
manent relief.  If  the  conditions  persist,  the  hair  may  fall  or  turn 
gray  upon  the  affected  side. 

Intercostal  Neuralgia  may  affect  one  or  more  of  the  intercostal 
nerves.  It  may  be  difficult  to  distinguish  between  this  disease  and 
pleurisy,  especially  when  the  pleuritic  adhesions  follow  the  nerve 
distribution.  The  lesions  of  the  ribs  and  the  related  vertebrae  are 
usually  easily  found,  easily  corrected,  and  the  relief  of  the  pain  is 
usually  immediate. 

Mastodynia  is  neuralgia  of  the  breast;  it  is  often  associated 
with  slight  edema,  often  localized.  This  arouses  fear  of  malig- 
nancy; which  increases  the  pain  and  tenderness.  Vomiting  may 
be  associated  with  the  paroxysms.  The  scar  left  from  an  old 
mastitis  may  add  to  the  difficulty  in  diagnosis.  The  condition  is 
usually  associated  with  rib  or  clavicular  lesions ;  the  correction  of 
these  relieves  the  pain;  this  and  the  explanation,  relieve  the  fears 
of  the  patient. 

Cervico-brachial  Neuralgia  may  affect  any  of  the  branches  of 
the  cervical  or  the  brachial  plexuses.  When  the  pain  is  bilateral, 
the  trouble  may  be  due  to  spinal  cord  disease,  or  disease  of  the 
vertebrae.  Neuralgia  due  to  bony  lesions  of  the  vertebrae  usually 
affects  one  arm  more  than  the  other;  rarely,  these  may  also  be 
bilateral.  Lesions  of  the  lower  cervical  or  upper  thoracic  vertebrae 
may  be  responsible;  usually  rib  and  clavicle  lesions  are  associated 
with  these.  Contraction  of  the  scaleni  may  raise  the  ribs,  so  that 
direct  pressure  is  exerted  upon  the  brachial  plexus.  The  clavicles 
may  be  too  low;  anterior  curve  of  the  neck — "ewe-neck,"  "bicycle 
neck" — with  tensions  upon  the  anterior  cervical  muscle  group. 


428  THE  PERIPHERAL  NERVES 

may  also  exert  direct  pressure  upon  nerve  plexuses.  Surgical 
cases  include  tumors,  scars,  and  calluses.  The  treatment  is  indi- 
cated in  the  etiology. 

Sciatica  (Neuralgia  of  the  sciatic  nerve)  is  a  very  severe  form, 
and  may  be  confused  with  spinal  cord  disease,  tumors  of  the  cauda 
equina,  the  pain  of  tabes  and  neuritis.  It  may  be  due  to  pressure, 
as  in  childbirth,  or  long  sitting  in  an  awkward  position;  or  to 
severe  constipation;  or  to  trauma,  in  addition  to  the  usual  causes 
of  neuralgia.  Lesions  of  the  innominates  or  of  the  fourth  and 
fifth  lumbar  vertebrae,  or  the  coccyx  are  constantly  present.  Ova- 
rian disease,  hip  disease,  pelvic  diseases  of  various  kinds,  may 
cause  a  reflex  pain,  with  muscular  contractions.  The  treatment  is 
that  of  the  causative  factors ;  rest,  with  the  leg  wrapped  in  cotton, 
gives  relief;  the  leg  should  be  very  gently  stretched  and  rotated, 
avoiding  undue  pain  in  the  manipulation.  The  manipulation  of 
the  tissues  around  Poupart's  ligament,  as  well  as  those  around  the 
sciatic  notch  and  along  the  course  of  the  nerve,  facilitate  better 
circulation  and  promote  recovery.  The  relief  will  not  be  apt  to 
be  permanent  until  the  bony  lesions  mentioned  have  been  corrected. 

Coccygodynia,  neuralgia  of  the  coccygeal  nerves,  is  most  fre- 
quently found  in  women.  It  may  occur  in  either  sex  as  the  result 
of  trauma  or  of  anal  diseases.  In  men  it  is  caused  by  stone,  or  by 
prostatic  disease ;  in  women,  by  ovarian  or  uterine  disease.  The 
coccyx  is  often  dislocated;  in  recent  injuries  it  may  be  easily 
replaced,  working  with  a  finger  in  the  rectum  and  a  thumb  on  the 
outside,  over  the  coccyx ;  sometimes  old  cases  are  easily  corrected ; 
more  often  the  treatment  must  be  repeated  for  some  weeks,  until 
the  tissues  either  become  sufficiently  relaxed  to  adapt  themselves 
to  the  abnormal  state,  or  better,  until  the  bone  remains  fixed  in  its 
normal  position.  If  the  joint  is  flexible,  with  normal  tone  of  the 
surrounding  tissues,  the  fact  of  its  malposition  is  of  comparatively 
small  importance.  The  pelvic  lesions  should  receive  proper  treat- 
ment, and  the  usual  ordinary  systemic  treatment  for  neuralgia  is 
indicated  in  most  cases. 

Visceral  Neuralgia,  lumbo-abdominal  neuralgia,  femoral,  obtu- 
rator and  genito-crural  neuralgias,  affect  the  nerves  mentioned;  the 
examination  of  each  patient  reveals  the  specific  causes  in  each 
case,  and  indicates  the  treatment.  These  neuralgias  are  rare,  and 
are  often  associated  with  other  diseases. 


NEURITIS 

Inflammation  of  a  nerve  trunk,  however  produced,  is  called 
neuritis.  When  the  inflammation  is  limited  to  a  single  nerve  trunk 
it  is  called   "local";  when   many   nerves,  or  all  the   nerves,   are 


NEURITIS  -  429 

involved  the  condition  is  called  "polyneuritis"  or  "multiple  neu- 
ritis." 

Pathology.  The  inflammatory  process  may  chiefly  involve  the  con- 
nective tissue  coverings  of  the  nerVe  trunks ;  "interstitial  neuritis,"  or  it  may 
affect  chiefly  the  axis  cylinders,  "parenchymatous  neuritis."  The  changes  in  the 
nerve  fiber,  in  either  case,  may  resemble  those  of  Wallerian  degeneration,  or  of 
simple  atrophy,  or  of  fatty  degeneration. 

Etiology.  Local  neuritis  is  usually  due  to  local  causes — chill- 
ing or  trauma ;  lesions  associated  with  arteriosclerosis ;  extension 
of  inflammation  from  neighboring  diseased  tissues ;  septic  foci,  bony 
lesions,  and  any  disturbances  of  the  circulation  of  the  nerve 
trunks.  Multiple  neuritis  has  usually  some  poison  as  its  c^use; 
alcohol,  lead,  arsenic  or  mercury,  extrinsic  poisons,  or  the  toxic 
effects  of  other  diseases,  as  typhoid,  syphilis,  malaria,  influenza, 
beri-beri — and  many  others,  or  the  poisons  arising  from  disturb- 
ances of  metabolism,  as  in  diabetes,  gout,  pregnancy,  arterioscle- 
rosis, pernicious  and  severe  secondary  anemias,  and  the  cachexias 
generally.  "Idiopathic  neuritis"  is  that  in  which  no  cause  of  the 
trouble  can  be  found;  such  cases  are  not  rare. 

Alcoholic  Neuritis  is  usually  multiple,  and  is  associated  with 
more  or  less  profound  mental  disturbances.  Other  symptoms  of 
chronic  alcoholism  are  usually  present,  (q.  v.)  When  the  mental 
deterioration  includes  delirium  or  hallucinations,  with  progressive 
dementia,  the  condition  is  called  "Korsakow's  psychosis"  or  "syn- 
drome." 

Arsenic  neuritis  is  not  usually  associated  with  mental  changes. 

Workers  in  rubber  and  silk  manufacturers  may  suffer  from 
neuritis  due  to  carbon  disulphide.  Frontal  headache  and  giddi- 
ness, with  the  symptoms  of  a  multiple  neuritis,  should  lead  to 
change  of  occupation. 

Saturnine,  or  lead,  neuritis,  affects  chiefly  the  muscles,  and  has 
little  or  no  pain.  "Wrist  drop"  and  "foot  drop"  are  almost  pathog- 
nomonic; the  "blue  line"  upon  the  gums,  "lead  colic,"  sometimes 
delirium,  "lead  encephalopathy,"  and  rarely  optic  neuritis,  may  be 
associated  with  the  neuritis. 

Beri-beri  is  a  specific  neuritis  (see  acute  infectious  diseases). 

Senile  neuritis  occurs  in  old  age,  and  is  probably  due  to  arterio- 
sclerosis. 

Diagnosis.  The  symptoms  of  neuritis  include  motor,  sensory 
and  trophic  phenomena.  Pain  varies ;  it  may  be  very  severe,  espe- 
cially is  this  true  in  local  neuritis.  The  nerve  is  sensitive  to  pres- 
sure, usually  along  its  entire  course.  Its  area  of  distribution  is 
hypersensitive,  and  the  tissues  around  the  vertebrae  of  the  segment 
of  origin  of  the  nerve  trunk  are  hypersensitive ;  this  is  true  whether 
any  bony  lesion  is  present  or  not.  Tactile  sensation  may  be 
lowered,  while  the  hypersensitiveness  to  pain  and  to  temperature 


430  THB  PERIPHERAL  NERVES 

changes  becomes  extremely  exaggerated.  Anesthesia  and  anal- 
gesia may  follow,  or  may  be  present  from  the  beginning  of  the  dis- 
order. Motor  disturbances  include  convulsive  movements  and 
twitching,  which  may  or  may  not  occasion  pain;  paralysis  may 
follow  the  convulsions,  or  may  be  present  from  the  beginning  of 
the  disorder.  Trophic  changes  include  a  peculiar  shining  appear- 
ance of  the  skin,  which  is  usually  reddened;  thickening  of  the 
nails,  and  dropping  or  whitening  of  the  hair,  or  rarely  an  over- 
growth of  coarse  hair  may  be  found  in  the  area  of  distribution  of 
the  affected  nerves.  Vasomotor  changes  include  variable  pallor 
and  reddenings,  and  sometimes  edema. 

Treatment.  The  treatment  depends  absolutely  upon  the  etio- 
logical factors  present  in  each  case,  plus  such  palliative  measures 
as  may  give  relief.  In  painful  cases,  the  affected  area  should  be 
well  protected  from  temperature  changes,  usually  by  wrapping  in 
warm  cotton  wool,  and  by  complete  rest.  Local  neuritis  must 
always  be  treated  with  complete  rest  of  the  affected  part,  if  pos- 
sible. Very  gentle  manipulations  or  none  are  to  be  given ;  massage 
is  to  be  omitted  during  the  painful  stages  of  any  neuritis.  It  is 
best  to  postpone  correction  of  lesions  closely  related  to  the  affected 
areas  until  after  the  acute  pain  has  disappeared.  Just  absolute  rest 
and  protection  is  the  best  thing  during  the  acute  stage  of  neuritis. 

After  the  acute  stage  has  subsided,  and  in  those  cases  in  which 
the  pain  is  not  severe,  the  course  of  the  nerve  trunk  from  the 
periphery  to  the  spinal  origin  should  be  investigated,  and  all  struc- 
tural perversions  corrected  as  gently  as  possible.  Corrections  of 
bony  lesions  must  be  made  in  such  a  manner  as  to  avoid  irritation 
to  the  sensory  nerves,  rarely  it  may  be  necessary  to  postpone  cor- 
rective work  until  the  pain  has  disappeared  completely.  The  cor- 
rections should  then  be  made,  in  order  to  prevent  later  attacks. 
Complete  rest  of  the  affected  limbs  is  important  during  the  entire 
course  of  the  disease. 

The  motor  changes  require  especial  care.  During  the  con- 
vulsive stages  the  affected  parts  are  to  be  kept  quiet,  and  every 
sensory  irritation  of  the  entire  body  avoided.  The  affected  muscles 
should  be  well  protected  from  chill,  usually  by  wrappings  and 
cotton  wool;  these  should  extend  well  beyond  the  affected  areas. 
When  paralysis  is  present,  during  the  acute  stage  there  must  be 
absolute  rest.  With  the  subsidence  of  the  symptoms  of  acute 
inflammation,  passive  movements,  then  active  movements  and 
massage  should  be  begun.  The  muscles  are  weakened,  and  over- 
work is  to  be  avoided.  The  patient  may  be  able  to  perform  move- 
ments while  he  is  in  a  warm  or  neutral  bath,  which  would  be 
impossible  out  of  the  water;  this  is  an  excellent  exercise. 


NEURITIS  431 

Trophic  disorders  may  lead  to  bed  sores;  these  are  avoided  by 
the  usual  good  nursing  and  baths.  A  water  or  air  bed  is  useful  in 
severe  cases. 

Neuritis  which  is  due  to  arteriosclerosis  should  receive  treat- 
ment for  that  condition  (see  arteriosclerosis).  Special  attention 
should  be  given  to  any  possible  septic  focus.  Whatever  poison  is 
active  should  be  removed  as  speedily  as  possible;  alcoholics  may 
have  to  be  brought  rather  gradually  to  abstinence;. other  poisons 
are  to  be  removed  at  once,  and  even  alcohol  can  sometimes  be 
suddenly  stopped.  Occupational  causes  must  be  met  by  change 
of  occupation.  Elimination  of  poisons  is  facilitated  by  thorough 
correction  of  the  lesions  and  the  reflex  rigidities  usually  present; 
especially  in  the  lower  thoracic  and  dorso-lumbar  region.  Baths, 
enemas,  special  exercises,  are  sometimes  indicated,  according  to 
individual  needs. 

The  following  treatment  is  illustrative: 

"As  the  general  system  was  much  run  down  I  advised  the  use  of  a  nutritious 
diet,  including  raw  eggs  and  milk  and  a  liberal  allowance  of  open  air.  The 
specific  treatment  consisted  in,  first  relaxing  the  contracted  cervical  muscles  fol- 
lowed by  gently  stretching  the  shoulder  muscles  and  those  of  arm  and  forearm 
and  the  ligaments  of  the  shoulder  and  elbow  joints.  This  was  preceded  by  deep 
inhibition  all  along  the  roots  and  trunks  of  the  affected  nerves,  thus  permitting 
deeper  adjustive  work.  The  nerves  were  gently  stretched  wherever  possible. 
The  subluxated  cervical  vertebrae  were  adjusted  during  the  second  month  of 
treatment.    The  upper  ribs  were  adjusted." — W.  B.  Keene. 

Prognosis.  In  favorable  cases,  the  recovery  may  be  complete. 
When  the  nerves  have  been  seriously  damaged,  some  anesthesias 
or  paralyses  may  remain  permanently.  The  death  of  the  axis 
cylinders  may  lead  to  atrophy  or  degeneration  of  the  nerve  cells 
of  the  anterior  horn  of  the  cord  and  the  sensory  ganglia;  later  ill 
effects  may  follow  from  these  changes.  When  the  inflammatory 
changes  affect  the  muscles  of  respiration,  death  may  occur  from 
asphyxia.  In  the  infectious  cases,  death  may  occur  from  heart 
failure,  thrombosis,  or  exhaustion. 

Prophylaxis.  The  use  of  arsenic  and  mercury  in  the  treat- 
ment of  diseases  is  much  less  frequent  than  formerly;  alcoholism  is 
decreasing;  modern  knowledge  of  nerve  surgery  prevents  many 
traumatic  cases ;  the  use  of  poisonous  substances  in  the  trades  is 
being  constantly  more  closely  supervised  and  controlled  by  law; 
all  of  these  factors  should  lead  to  great  diminution  of  the  number 
of  cases  of  neuritis. 

NEUROMATA 

Nerve  tumors  are  rare;  they  cause  varying  degrees  of  pain  and  incon- 
venience. 

Amputation  Neuromata  (stump  neuromata)  follow  amputation  of  a  limb, 
or  section  of  a  nerve.     The  nerve  fibers  grow  out  into  the  tissues,  and  often 


432  THE  PERIPHERAL  NERVES 

form  bulbous  masses,  or  coiled  fibers.    They  are  usually  avoided  by  modern 
methods  of  amputation;  the  treatment  consists  of  surgical  excision. 

Nerve-Tnmk  Neuromata  are  tumors  upon  the  nerves;  they  may  be  true 
or  false,  and  may  be  extremely  numerous.  They  may  occasion  no  symptoms, 
or  may  be  painful.  The  only  treatment  is  surgical;  and  that  is  not  often  satis- 
factory, on  account  of  the  number  of  the  tumors. 

True  Neuromata  include  nerve  fibers,  rarely  nerve  cells,  with  connective 
tissues  for  support,  as  in  normal  nervous  tissues. 

False  Neuromata  are  connective  tissue  tumors  growing  upon  nerve  trunks. 


REGENERATION   OF  NERVE   FIBERS 

When  a  nerve  trunk  has  been  cut,  or  its  continuity  severed  in  any  way,  the 
fibers  degenerate  peripherally  to  their  endings,  and  centrally  for  one  or  several 
nodes.  The  fibers  and  the  nerve  cells  of  origin  undergo  certain  changes,  but 
do  not  necessarily  die.  If  the  cut  ends  are  brought  together,  or  if  the  pressure 
be  removed,  or  other  causes  of  injury  be  removed,  regeneration  may  occur. 
This  means  that  the  ends  of  the  nerve  fibers  above  the  degenerative  processes 
begin  to  send  out  fibrils,  which  ultimately  grow  into  the  peripheral  remnant 
of  the  nerve  trunk,  and  reach  the  original  field  of  distribution.  Function  is 
thus  restored  with  varying  degrees  of  completeness. 

In  surgical  cases,  the  nerve  ends  should  be  sutured.  Regeneration  begins 
within  a  few  days,  and  the  fibers  grow  at  an  average  rate  of  about  one  millimeter 
each  day — this  is  subject  to  great  variation.  In  cases  in  which  the  nerve  is 
injured  by  pressure,  as  by  tumors,  exostoses,  and  other  structural  factors,  the 
removal  of  the  pressure  may  be  followed  by  regeneration  only  slowly,  if  at  all, 
and  regeneration  is  less  complete  than  in  surgical  cases. 

Regeneration  may  be  facilitated  by  correct  treatment.  The  field  of  distri- 
bution of  the  injured  nerve  trunk  must  be  kept  in  normal  condition  by  bathing, 
massage,  and  sometimes  by  electrical  stimulation  of  the  muscles  left  without 
the  normal  nerve  stimulation.  Volitional  attempts  to  move  the  paralyzed  mus- 
cles seems  to  exert  a  helpful  influence  upon  the  motor  nerve  cells. 


CHAPTER  XL 
DISEASES  OF  THE  CRANIAL  NERVES 

The  Olfactory  Nerves  are  peculiar  in  having  no  medullary 
sheaths.  They  are  not  often  diseased.  Inflammations  of  the  nasal 
membranes  may  destroy  the  olfactory  nerve  endings,  in  which  case; 
olfactory  anesthesia  or  anosmia  results — loss  of  the  sense  of  smell. 
Injury  to  the  nerve  trunks  or  the  olfactory  bulbs  or  tracts  may 
be  due  to  fractures  of  the  skull,  brain  tumors,  or  meningitis. 
Anosmia  results  from  abnormal  dryness  of  the  nasal  membranes, 
as  in  early  acute  rhinitis,  or  in  disease  of  the  nasal  branches  of 
the  fifth  cranial  nerve. 

Hyperosmia,  olfactory  hyperesthesia,  may  be  present  in  hyste- 
ria or  insanity,  or  as  a  congenital  peculiarity.  Delicacy  of  smell 
comparable  to  that  of  wild  animals  or  dogs  may  be  present  occa- 
sionally in  such  individuals.  Parosmia  is  often  due  to  partial  loss 
of  smell;  occasionally  as  a  hysterical  symptom  it  may  be  pro- 
nounced. Olfactory  hallucinations  are  often  present  as  epileptic 
aurse ;  they  may  be  present  in  insanity  and  in  hysteria. 

In  testing  for  olfactory  variations,  it  is  necessary  to  employ 
odorous  substances  which  do  not  affect  the  common  sensations; 
ammonia,  smelling  salts,  pepper,  act  upon  the  fifth  nerve  and  are 
useless.  Aromatic  oils  are  most  useful  for  such  tests.  It  is  neces- 
sary to  avoid  too  great  stimulation  with  these,  and  very  small 
quantities  give  most  accurate  results. 

Treatment  of  the  olfactory  nerve  disturbances  is  usually  very 
unsatisfactory.  Hysteria  which  shows  olfactory  symptoms  is 
usually  obstinate,  (q.  v).  Nasal  diseases  may  be  treated;  this  may 
relieve  the  olfactory  disturbance  to  a  certain  extent.  The  tem- 
porary loss  of  smell  due  to  acute  rhinitis  disappears  completely,  in 
most  cases.  In  all  other  olfactory  disturbances  the  prognosis  is 
bad  for  recovery.  Fortunately,  olfactory  sensations  are  not  essen- 
tial to  life  or  to  cornfortable  living. 

The  Optic  Nerves.  Normal  vision  depends  upon  the  activity 
of  many  nerves — the  retina  and  the  optic  nerves ;  the  sympathetic 
nerves  which  control  the  circulation,  nutrition,  and  the  action  of 
the  intrinsic  eye  muscles ;  and  the  motor  nerves  which  control 
the  extrinsic  muscles.  The  activities  of  several  brain  centers  are 
also  essential  to  normal  vision. 

The  Retina  is  subject  to  disturbances  of  several  types. 

Toxic  Amblyopia  is  most  often  due  to  tobacco  or  alcohol ;  less 
often   to   lead   or   other   poisoning.     Central    scotoma,   especially 

433 


434  THE  CRANIAL  NERVES 

affecting  the  red-gjeen  fibers,  is  usually  the  first  symptom ;  this  is 
followed  by  progressive  loss  of  vision.  The  disturbance  may  be  a 
retro-bulbar  neuritis. 

Hemeralopia  (day  blindness)  is  characterized  by  inability  to 
see  clearly  in  a  bright  light,  but  vision  is  very  clear  in  dim  light. 
It  may  be  due  to  abnormal  dilation  of  the  pupil;  to  albinism,  cat- 
aract or  it  may  not  be  possible  to  find  the  cause  after  careful 
examination. 

Nyctalopia  (night  blindness)  is  most  often  due  to  syphilitic 
retinitis;  less  often  to  abnormal  constriction  of  the  pupils,  and  to 
retinal  fatigue.  In  this  disturbance  vision  is^practically  normal  in 
a  bright  light,  but  fails  completely  in  dim  light. 

Retinitis  is  characterized  by  progressive  failure  in  vision,  and 
its  diagnosis  is  based  upon  the  retinal  examination ;  this  shows 
the  disease  before  the  vision  is  affected,  and  should  be  made  as  a 
routine  procedure  in  cases  in  which  the  condition  is  suspected. 
Albuminuric  retinitis  may  be  the  first  symptom  of  chronic  inter- 
stitial nephritis;  it  may  occur  in  any  nephritis.  The  retina  shares 
and  sometimes  precedes  edema  of  other  parts  of  the  body.  Retinal 
hemorrhages  are  frequent  and  may  be  serious. 

Syphilitic  Retinitis  is  usually  associated  with  choroiditis;  it 
occurs  late  in  the  disease.  There  are  whitish  or  opalescent  patches 
upon  the  retina. 

Detachment  of  the  Retina  is  present  in  wasting  diseases;  it  is 
due  to  diminished  intra-ocular  pressure  or  to  exudates  back  of  the 
retina.  Heavy  falls,  blows  upon  the  head,  and  suddenly  produced 
cervical  lesions  are  causative. 

Pigmentary  Retinitis  is  chronic,  usually  attacks  young  adult? 
with  hereditary  syphilis  or  some  wasting  disease;  it  is  associated 
with  progressively  increasing  pigmentary  deposits  upon  the  retina, 
with  gradual  loss  of  vision  to  blindness. 

Retinal  Hemorrhages  occur  in  many  systemic  diseases;  nephri- 
tis, leukemia,  purpura ;  scurvy  ;  pernicious  anemia ;  arteriosclerosis ; 
under  conditions  associated  with  high  blood  pressure,  during  par- 
turition or  muscular  strain ;  it  is  recognized  by  the  retinal  exam- 
ination. The  blood  may  be  absorbed  and  vision  restored,  or  the 
injury  may  be  permanent. 

Choked  Disk  (papilledema)  is  a  condition  in  which  swelling 
or  edema  of  the  portion  of  the  retina  occupied  by  the  optic  nerve 
in  transit  causes  it  to  project  forward.  It  is  recognized  by  the 
retinal  examination,  and  is  present  in  nephritis  and  in  all  condi- 
tions associated  with  increased  intracranial  pressure.  It  is  an 
important  factor  in  the  diagnosis  of  brain  tumor  and  certain  other 
diseases. 


THE  OPTIC  NERVES  435 

Optic  Neuritis  is  due  to  the  causes  of  neuritis  elsewhere  (q.  v.) 
especially  to  syphilis,  alcoholism,  and  nephritis ;  mild  cases  may  be 
due  to  refractive  errors.  If  the  process  continues,  optic  nerve 
atrophy  results.  The  treatment  is  indicated  by  the  etiology.  Vis- 
ion may  not  be  changed  at  first;  the  diagnosis  can  usually  be 
made  by  the  retinal  examination.     Pain  is  not  present. 

Optic  Nerve  Atrophy  occurs  in  multiple  sclerosis,  and  in  the 
parasyphilitic  diseases,  tabes  dorsalis,  paretic  dementia  and  tabo- 
paralysis;  it  may  be  the  first  symptom  observed  in  these  diseases. 
It  may  result  from  optic  neuritis,  may  be  hereditary,  and  is  present 
in  amaurotic  family  idiocy.  It  is  characterized  by  variations  in 
the  color  sense,  followed  by  gradual  loss  of  vision  to  blindness. 

Destructive  Lesion  of  either  optic  nerve  causes  blindness  in  the 
corresponding  eye,  with  almost  total  loss  of  light-reflex  in  that 
eye.  Inflammatory  conditions  of  either  eye  may  affect  the  other 
eye ;  for  this  reason  surgical  removal  of  an  injured  eye  is  often 
required  in  order  to  preserve  the  normal  eye  from  injury. 

The  Optic  Chiasm  is  injured  by  tumors  of  the  pituitary  body  or 
by  basal  meningitis.  The  decussating  fibers  are  chiefly  affected, 
in  most  cases,  and  the  result  is  blindness  of  the  nasal  halves  of 
both  retinae;  so  that  the  patient  seems  to  be  looking  forward  into 
a  tunnel.  The  macula  retains  its  vision,  and  its  field  occupies 
part  of  the  outermost  limit  of  vision,  in  both  eyes. 

The  Optic  Tracts  are  also  affected  by  tumors  and  basal  menin- 
itis;  lesions  anterior  to  the  quadrigemina  usually  affect  the  motor 
nerves  of  the  eyeball  and  sometimes  other  cranial  nerves;  a  ray 
of  light  thrown  upon  the  blind  half  of  the  retina  in  such  cases 
may  initiate  pupillary  contraction.  This  reaction  is  not  always 
present.  Lesion  of  either  optic  tract  causes  blindness  upon  the 
same  side  in  both  retinae — bilateral  homonymous  hemianopsia. 

The  Visual  Cortex — i.  e.,  the  region  of  the  cuneus  and  the  cal- 
carine  fissure — may  be  injured  by  blows,  fragments  of  skull  or 
osteomata;  thickenings  of  the  dura,  however  produced;  tumors  of 
various  kinds,  hemorrhage,  or  softening.  When  one  side  is 
destroyed,  bilateral  homonymous  hemianopsia  is  produced ;  when 
both  sides  are  destroyed,  blindness  may  result,  or  the  macula  may 
escape,  leaving  fairly  good  vision  for  direct  fixation.  When  the 
neighboring  cortical  tissue  is  destroyed,  memory  for  the  signif- 
icance of  things  seen  may  be  lost ;  such  a  patient  sees  fairly  clearly, 
but  without  understanding;  he  cannot  read,  nor  recognize  persons; 
the  condition  is  called  "mind  blindness."  When  an  irritative  lesion, 
as  a  throbbing  aneurysm,  affects  the  cuneus  or  calcarine  fissure, 
flickering  lights,  vague  visual  sensations  of  several  kinds,  are  pres- 
ent ;  when  the  neighboring  or  overflow  areas  are  so  affected,  mem- 
ories appear  as  visions,  and  various  visions  of  angels,  dead  friends. 


436  THB  CRANIAL  NERVES 

etc.,  may  be  described  very  clearly  and  in  great  detail.  Such  occur- 
rences are  not.  rare  in  old  persons,  and  in  early  cerebral  degen- 
erations. 

The  motor  nerves  of  the  eyeball  include  both  somatic  and  vis- 
ceromotor fibers.  The  visceromotor  fibers  include  those  which 
govern  the  blood  vessels,  the  pupils,  the  lens,  and  the  nonstriated 
fibers  of  the  levator  palpebrae  and  the  capsule  of  Tenon.  The  cen- 
ters of  the  third  nerve  send  fibers  which  terminate  in  the  ciliary 
ganglion  (sympathetic),  and  these  innervate  the  circular  fibers  of 
the  iris  and  the  ciliary  muscle.  From  this  and  related  centers, 
fibers  pass  to  the  region  of  the  upper  thoracic  spinal  segments; 
fibers  from  the  gray  matter  of  that  area  pass  to  the  superior 
cervical  sympathetic  ganglion,  whence  the  gray  fibers  pass  to  the 
radiating  muscle  fibers  of  the  iris,  to  the  capsule  of  Tenon,  the 
nonstriated  fibers  of  the  levator  palpebrae,  and  the  blood  vessels 
of  the  orbit.  The  fibers  which  reach  the  eye  by  way  of  the  upper 
thoracic  spinal  segments  may  be  affected  by  lesions  of  the  upper 
thoracic  vertebrae,  and  indirectly  by  lesions  of  the  cervical  verte- 
brae. Thus,  functional  disorders  of  circulation  of  the  conjunctivae 
and  the  eyeball;  ptosis,  unequal  and  irregular  pupils,  may  be 
caused;  these  may  lead  to  later  and  more  serious  disturbances  of 
the  orbital  tissues.  Correction  of  the  lesions  as  found  is  the  only 
treatment  required  at  an  early  time,  but  if  the  disturbance  has 
been  active  for  months  or  years,  the  tissue  changes  may  be  so 
marked  that  considerable  time,  and  perhaps  other  treatment,  are 
necessary. 

Disease  of  the  nerve  centers  or  of  the  meninges  along  which  the 
nerves  pass  may  cause  disturbed  function  of  the  nerves,  either 
irritative  or  destructive,  as  the  case  may  be. 

Iridoplegia  is  paralysis  of  the  muscles  of  the  iris ;  several  forms 
are  described. 

Myosis,  or  contraction  of  the  pupil,  may  be  produced  by  an 
irritative  lesion  affecting  the  third  nerve  fibers,  or  by  paralysis 
6i  the  sympathetic  fibers  from  the  upper  thoracic  segments.  It  is 
present  in  locomotor  ataxia;  sometimes  in  tabo-paralysis  and 
paretic  dementia.  In  these  cases  it  may  affect  the  pupils  unequally. 
Tumors,  etc.,  pressing  upon  the  cervical  sympathetic  ganglion  or 
the  cervical  sympathetic  cord  may  produce  unequal  pupils.  In 
any  case,  the  fibers  in  either  pupil  may  be  unequally  contracted,  .so 
that  a  "comma  pupil"  or  "feline  pupil"  is  produced. 

Mydriasis,  or  dilatation  of  the  pupil,  may  arise  from  irritative 
lesion  of  the  sympathetics  or  from  paralysis  of  the  third  nerve 
fibers  or  visceromotor  center  of  the  third  nerve.  Lesions  of  the 
upper  thoracic  vertebrae  are  most  often  followed  by  slight  mydri- 
asis; this  may  be  unequal.  -• 


THE  VISUAL  CENTERS  437 

Cycloplegia  is  paralysis  of  the  ciliary  muscle;  vision  is  un- 
changed for  distant,  but  accommodation  for  near  objects  is  lost. 

Accommodation  Iridoplegia  is  characterized  by  absence  of  the 
contraction  of  the  pupils  on  near  vision.  The  pupils  may  contract 
when  the  lids  are  closed,  or  such  motion  is  attempted.  It  is  most 
often  found  in  paretic  dementia. 

Ophthalmoplegia  Interna  is  characterized  by  loss  of  the  pupil- 
lary reflexes,  both  for  light  and  for  distance. 

Argyll-Robertson  Pupil  is  one  in  which  the  pupils  change  nor- 
mally to  distance  variations,  but  not  to  light,  "light  reflex  irido- 
plegia." 

The  somatic  motor  nerves  are  distributed  to  the  extrinsic  eye 
muscles.  These- may  be  irritated  and  thus  spasm  is  produced;  or 
destroyed,  when  paralysis  follows.  Functional  variations  may 
occur  also ;  usually  either  twitchings  of  the  muscles  or  weakness 
of  one  or  more  of  the  eye  muscles  is  produced. 

Lesions  of  the  extrinsic  motor  nerves  occur  as  the  result  of 
syphilitic  or  alcoholic  meningitis,  brain  tumors,  fracture  of  tlie 
base  of  the  skull,  axid  in  other  less  well  recognized  conditions.  The 
sixth  nerve  has  the  longer  course  upon  the  meninges,  and  is  most 
often  affected. 

These  nerves  innervate  special  muscles — the  sixth,  the  abdu- 
cens;  the  fourth,  the  superior  oblique;  the  third,  all  the  others — 
but  the  nuclei  of  these  are  so  intimately  related,  especially  in  the 
control  of  antagonistic  muscles,  and  in  so  many  cases  fibers  arising 
in  one  nucleus  are  distributed  with  the  fibers  of  another  nerve,  of 
the  same  or  of  opposite  sides,  that  the  special  symptoms  observed 
do  not  always  indicate  the  exact  anatomical  lesions. 

Nystagmus  is  a  rapid  motion  of  the  eyeballs,  due  to  alternating 
contractions  of  muscle  opponents.  It  is  rarely  a  congenital  neu- 
rosis; and  is  a  symptom  in  Friedrich's  ataxia,  insular  sclerosis, 
Meniere's  disease,  meningitis,  and  other  diseases  of  incoordination. 
It  may  appear  temporarily  on  voluntary  movement  in  eyes  with  a 
weakened  or  partially  paralyzed  muscle.  It  is  usually  present  in 
albinism. 

Strabismus  occurs  when  the  weakness  of  any  muscle  prevents 
correspondence  of  the  axes.  The  deviation  of  the  paralyzed  eye 
is  called  the  "primary  deviation";  when  this  eye  is  fixed,  the  nor- 
mal eye  suffers  from  overaction  of  the  corresponding  muscle;  this 
is  termed  "secondary  deviation."  It  does  not  occur  in  strabismus 
due  to  spasm,  and  its  presence  indicates  paralysis. 

Ocular  Vertigo  is  due  to  the  effect  produced  in  consciousness 
by  imperfect  vision,  whereby  the  objects  appear  farther  away  than 
normal,  on  account  of  the  increased  effort  required  for  fixation  in 
partially  paralyzed   eyes;  the   incongruousness  between   the   eye 


438  THE  CRANIAL  NERVES 

efforts  and  the  information  of  other  senses  gives  a  peculiar  and 
distressing  sense  of  dizziness. 

Diplopia,  or  double  vision,  may  result  from  strabismus.  It 
occurs  also  as  a  neurosis,  and  in  wasting  diseases. 

The  Fifth,  Trigeminal,  or  Trifacial,  nerve  has  such  a  wide  area  of 
nuclei  of  origin  and  insertion,  and  its  fibers  so  intricately  interlace 
with  the  fibers  of  other  nerves,  that  it  is  difficult  to  decide,  in  any 
given  patient,  whether  the  fifth  nerve  alone  is  involved  or  whether 
other  nerves  also  are  involved.  Its  broad  and  long  nuclear 
relations  render  it  very  improbable  that  a  nuclear  disease  affecting 
the  fifth  nerve  does  not  also  affect  other  nerves.  The  nerve  trunk 
may  be  variously  diseased,  rarely  as  a  whole,  but  frequently  as  one 
of  its  branches.    (See  neuralgia.) 

Sensory  disturbances  of  the  fifth  nerve  are  varied.  Irritative 
lesions  cause  various  neuralgic  pains  and  paresthesias  in  the  area 
of  distribution.  Abnormalities  of  taste  vary  in  individuals,  appar- 
ently. Parageusias  are  recorded  in  irritative  fifth  nerve  lesions;  in 
other  cases  with  apparently  identical  pathology,  the  sense  of  taste 
remains  unaffected. 

Destructive  lesions  cause  anesthesia  in  the  area  of  distribution 
of  the  nerve,  or  of  its  injured  branches.  Variations  in  the  sense  of 
taste  are  sometimes  reported.  Injury  of  the  sensory  portion  of 
the  nerve  causes  various  trophic  changes  also.  Dryness  of  the 
olfactory  membrane  may  cause  anosmia;  dryness  of  the  conjunc- 
tivae may  result  in  injury  to  the  orbital  tissues.  Corneal  ulcers  are 
frequent.  Herpes  and  increased  liability  to  infection  result  from 
the  loss  of  sensory  impulses,  or  of  trophic  control  of  the  tissues. 

Irritative  motor  lesions  cause  either  tonic  or  clonic  spasm  of 
the  muscles  of  mastication.  Tonic  spasm  is  most  common  in 
tetanus,  tetany,  and  hysteria.  The  clonic  spasms  most  often 
occur  with  other  muscular  disturbances,  as  in  paralysis  agitans, 
chorea,  and  general  convulsions. 

Destructive  lesions  cause  paralysis  of  the  muscles  of  mastica- 
tion. The  fibers  of  the  fifth  which  supply  the  mylohyoid,  digas- 
tric, and  tensor  tympani,  do  not  show  symptoms  when  the  nerve 
is  paralyzed.  It  must  be  remembered  that  the  area  supplied  by  the 
fifth  nerve  is  overlapped  greatly  by  other  nerves,  and  that  there  is 
also  much  overlapping  of  the  right  and  left  areas  of  innervation. 

The  Seventh,  or  facial  nerve  is  the  nerve  which  controls  the 
muscles  of  expression.  It  is  frequently  subject  to  functional  and 
structural  diseases;  and  the  diagnosis  of  its  various  affections  is 
usually  rather  easy. 

Sensory  disturbances  are  not  marked.  Common  sensation  in 
the  skin  and  mucous  membranes  of  the  lower  part  of  the  face 


THB  FACIAL  NBRVBS  439 

and  the  mouth  is  sometimes  slightly  changed,  in  lesions  of  the 
nerve  trunk.  Loss  of  taste  is  variable,  and  occurs  when  the  nerve 
lesion  lies  between  the  geniculate  ganglion  and  the  beginning  of 
the  chorda  tympani  nerve.  Disturbance  in  the  buccal  secretion, 
occurs  when  the  lesion  lies  centrally  to  the  beginning  of  the  chorda 
tympani ;  this  is  usually  a  diminution  of  the  salivary  flow. 

Motor  disturbances  may  be  irritative  or  paralytic;  paralysis 
may  be  of  the  upper  or  the  lower  neuron  type. 

Spasms  of  the  facial  muscles  may  be  either  functional  or  asso- 
ciated with  gross  lesions.  Functional  disturbances  include  the 
various  tics,  choreic  movements,  and  hysterical  neuroses,  (q.  v.) 
Athetoid  movements  may  appear  in  lesions  of  the  basal  ganglia, 
especially  the  striata,  whether  congenital  or  due  to  tumors,  etc., 
and  are  often  associated  with  other  localizing  symptoms.  Variable 
spasms  may  be  due  to  injury  to  the  facial  nerve  as  the  result  of 
middle  ear  disease. 

The  bony  partition  between  the  middle  ear  and  the  facial 
nerve  is  thin,  often  defective,  and  is  easily  penetrated  in  diseased 
conditions.  The  nerve  is  thus  left  with  only  membranes ;  these  may 
even  be  destroyed ;  and  only  the  nerve  sheaths  are  left  for  protec- 
tion. Anything  which  causes  variation  in  the  circulation  through 
the  ear  membranes,  such  as  cold,  nervous  disturbances,  bony 
lesions  of  the  cervical  and  upper  thoracic  vertebrae,  extension  of 
infection  from  the  throat  or  other  tissues  may  thus  bring  pressure 
upon  the  nerve  trunk,  or  permit  the  infection  of  the  surrounding 
tissues.  ^ 

When  the  pressure  thus  produced  is  variable,  the  spasms  vary 
in  intensity  and  in  location.  Increasing  pressure  causes  first 
spasm,  then  paralysis  of  muscle  fibers  or  muscle  groups,  in  turn; 
sensory  disturbances  and  secretory  disturbances  may  also  vary, 
according  as  the  pressure  irritates,  inhibits,  or  destroys  the  nerve. 
In  many  cases  supposed  to  be  due  directly  to  cold,  the  middle  ear 
disease  is  the  intermediate  factor  in  the  etiological  series  of  events. 

Paralysis  of  any  branch  of  the  facial  nerve  is  usually  due  to 
injury  of  that  trunk  alone;  a  comparison  of  the  symptoms  with 
the  anatomical  distribution  of  the  nerve  branches  will  usually  give 
the  location  of  the  injury  within  narrow  limits. 

Bell's  Palsy  is  lower  neuron  paralysis  of  the  seventh  nerve.  It 
is  characterized  by  flaccidity  of  muscles,  which  do  not  react  to 
reflex  stimulation  nor  to  emotional  states;  and  which  give  the 
reaction  of  degeneration  to  the  electric  tests.  The  lips  and  eye- 
lids drop,  and  the  saliva  and  tears  flow  freely,  as  a  rule.  After 
some  weeks  or  months,  the  paralyzed  muscles  shrink,  causing 
various  deformities  of  the  face.  Many  of  these  cases  can  be  com- 
pletely relieved  by  early  attention  to  the  upper  cervical  region. 


440  ^  THB  CRANIAL  NERVES 

The  muscles  of  expression  have  little  or  no  bony  attachments; 
and  antagonistic  muscles  are  lacking  or  are  not  exactly  antag- 
onistic; thus  the  effects  of  this  later  shrinking  of  the  muscles  is 
not  like  that  produced  in  paralyses  of  the  other  parts  of  the  body, 
where  the  contractions  resulting  from  paralysis  are  associated 
with  hypertension  of  the  muscle  antagonists.  The  shrinking  of 
the  facial  muscles  produces  a  mask-like  drawing  of  the  face,  so 
that  at  first  the  normal  side  appears  to  be  the  paralyzed  one. 
Attempts  at  whistling  or  blowing  show  the  true  condition. 

Hyperacusia  is  said  to  be  due  to  paralysis  of  the  stapedius,  in 
facial  nerve  paralysis.  Probably  the  effects  produced  upon  hear- 
ing in  Bell's  palsy  are  more  often  due  to  the  fact  that  disease  of 
the  middle  ear  is  a  common  cause  of  the  paralysis  rather  than  that 
the  paralysis  itself  exerts  any  marked  effect  on  the  intrinsic  muscles 
of  the  ear;  occasionally,  no  doubt,  the  latter  factor  is  of  some 
importance. 

Upper  neuron  paralysis  of  the  facial  nerve  is  characterized  by 
increased  tension  of  the  affected  muscles;  the  mouth  is  drawn 
upwards,  the  wrinkles  are  deepened;  saliva  and  tears  are  normal; 
reflexes  are  exaggerated  or  normal ;  taste  is  normal  or  very  slightly 
affected;  emotional  states  may  cause  movements  of  the  affected 
muscles  in  variable  degree  or  the  paralysis  may  involve  the  emo- 
tional reactions  also.  Rarely  the  face  alone  is  involved  in  upper 
neuron  paralysis ;  usually  the  limbs  are  also  included. 

Lesion  of  the  pons,  taking  in  the  decussation  of  the  nerves, 
may  cause  bilateral  facial  paralysis.  Two  lesions,  affecting  the 
facial  centers,  may  cause  bilateral  paralysis;  occasionally  an  upper 
neuron  paralysis  on  one  side  may  be  associated  with  a  lower  neuron 
paralysis  of  the  opposite  side.  Various  complicating  factors  may 
occur  under  such  conditions. 

Treatment.  In  addition  to  the  usual  features  of  treatment  of 
cranial  nerve  diseases,  the  facial  nerve  should  receive  attention 
from  the  standpoint  of  the  ear  affection.  Relief  of  the  diseased 
condition  of  the  middle  ear  may  prevent  further  development  of 
the  paralysis  of  the  seventh  nerve,  and  may  permit  a  return  to 
normal  function  on  the  part  of  fibers  which  have  been  affected 
by  the  pressure  but  have  not  been  destroyed. 

In  cases  which  do  not  yield  to  conservative  measures,  the 
surgery  of  the  nerve  trunks  may  be  useful.  The  hypoglossal  may 
be  sectioned,  and  its  central  end  sutured  to  the  peripheral  end  of 
the  facial ;  paralysis  of  the  hypoglossal  is  less  serious  and  annoy- 
ing; much  reeducation  is  necessary  before  restoration  of  normal 
Condition  of  the  facial  muscles. 

The  Eighth  cranial  nerve  is  composed  of  two  physiologically 
distinct   parts.     The    Auditory   portion   is   stimulated   by   sound 


THB  AUDITORY  NERVES  441 

waves,  and  is  important  in  conveying  these  impulses  to  the  brain. 
Higher  cerebral  activities  depend  in  great  measure  upon  the  sounds 
received  by  the  auditory  apparatus  and  the  nervous  effects  of 
these  in  the  central  nervous  system. 

The  Vestibular  portion  is  stimulated  by  varying  pressure  con- 
ditions within  the  semicircular  canals,  and  is  important  in  the 
effects  produced  upon  the  coordinating  apparatus.  Little  informa- 
tion is  conveyed  by  this  apparatus,  but  equilibrium  is  maintained 
and  the  efficiency  of  certain  body  movements  is  secured  througlf 
the  vestibular  apparatus. 

Deafness  may  be  due  to  any  one  or  more  of  a  great  number 
of  causes.  The  membrane  of  the  middle  ear  is  continuous  with 
that  of  the  Eustachian  canal  and  the  pharynx;  infections  of  this 
region  are  readily  carried  to  the  ear,  with  varying  subsequent 
effects  upon  the  otoliths,  tympanum,  and  lining  membranes.  In- 
jury to  the  internal  ear,  affecting  the  cochlea  with  the  membrane, 
organ  of  Cortj,  and  nerve  endings  may  follow  middle  ear  disease, 
or  may  arise  independently,  from  hemorrhage,  infections,  the 
effects  of  alcoholism  or  syphilis.  Deafness  may  be  due  to 
involvement  of  the  auditory  nerve  itself,  either  within  the  canal 
in  the  petrous  portion  of  the  temporal  bone,  or  within  the  skull. 
Cerebellopontine  tumors  often  cause  deafness;  this  may  be  a  very 
early  symptom. 

Atrophy  of  the  auditory  nerve  may  occur  in  tabes.  Injury  to 
the  auditory  cortex  may  interfere  with  hearing,  but  rarely  causes 
deafness. 

Mind  or  word  deafness  is  due  to  injury  of  the  cerebral 
cortex  in  the  auditory  overflow  areas — the  psychic  auditory  areas. 
In  this  condition  hearing  is  reasonably  acute,  but  the  significance 
of  things  heard  is  lost — words  are  heard,  as  if  they  were  in  a 
foreign  language.  A  certain  degree  of  aphasia  is  usually  asso- 
ciated with  this  condition. 

Hyperacusis  is  a  condition  in  which  all  sounds  are  intensified. 
Paralysis  of  the  stapedius  muscle  allows  low  tones  to  be  heard 
with  especial  distinctness.  Neurasthenic  individuals  are  affected 
uncomfortably  by  sounds,  and  complain  of  their  loudness ;  rarely 
is  audition  more  efiicient  in  neurasthenia.  In  hysteria,  there  is 
often  increased  hearing;  sounds  may  be  heard  and  interpreted 
with  greater  facility  than  in  normal  individuals. 

Dysacusis  is  difficult  hearing.  It  is  sometimes  applied  to  partial 
deafness.  It  may  be  due  either  to  middle  ear  or  to  labyrinthine 
disease.  When  due  to  middle  ear  disease,  bone  conduction  is 
better  than  air  conduction;  the  tuning  fork  placed  upon  the  skull 
can  be  heard  longer  than  when  held  near  the  ear,  in  the  air.    When 


442  THB  CRANIAL  NERVES 

the  labyrinth  or  the  nerve  itself  is  at  fault,  bone  conduction  and 
air  conduction  are  about  equally  diminished. 

Tinnitus  Auirium,  or  ringing  in  the  ears,  may  be  due  to  a  num- 
ber of  very  different  causes.  In  anemic  or  neurotic  individuals 
they  appear  to  be  due  to  an  abnormal  appreciation  of  the  sounds 
produced  by  the  circulation  of  the  blood — these  are  synchronous 
with  the  pulse.  Noises  "which  are  unnoticed  by  normal  individuals 
may  arouse  unpleasant  sensations ;  this  can  be  determined  by  clos- 
ing the  ears,  and  noticing  the  cessation  of  the  sounds  supposed  to 
be  tinnitus. 

Hardened  ear  w^ax  causes  varying  crackling,  ringing,  buzzing 
noises.  Other  causes  of  tinnitus,  which  affect  the  middle  ear  or 
the  labyrinth  include  the  effects  of  poisons,  as  quinine,  alcohol, 
or  certain  diseases,  otitis  media,  arteriosclerosis,  brain  tumor, 
or  aneurysm.  Irritation  of  the  cervical  sympathetic  chain,  and 
bony  lesions  affecting  the  cervical  and  upper  thoracic  spinal  cen- 
ters, may  cause  tinnitus,  through  varying  the  circulation  through 
the  ears  or  the  general  blood  pressure.  Attacks  of  migraine  and 
epilepsy  may  be  preceded  by  tinnitus. 

Noises  due  to  involvement  of  the  nerve  trunk  are  less  common. 
Irritative  injuries  to  the  auditory  cortex  cause  sounds  which  are 
usually  complex;  words,  and  even  long  speeches,  often  associated 
with  visual  hallucinations,  may  be  reported  by  the  patient  with 
great  detail ;  he  is  usually  very  certain  that  these  have  an  extraso- 
matic  origin. 

Meniere's  Disease.  Disease  of  the  labyrinth,  associated  with 
vertigo  and  disturbances  in  equilibrium,  usually  with  tinnitus  and 
partial  deafness,  sometimes  with  vomiting,  is  called  Meniere's 
Disease.  It  is  most  common  in  men  past  thirty,  and  is  due  chiefly 
to  syphilis,  alcoholism,  gout,  senility,  or  hemorrhage  into  the 
vestibule  or  the  semicircular  canals.  It  may  be  precipitated  by  gas- 
tric disturbance,  emotional  shock,  or  blows  or  falls.  A  single  attack 
may  persist,  or  a  series  of  attacks  may  occur;  unless  the  cause  is 
removed,  the  vertigo,  nausea,  and  other  vestibular  symptoms  per- 
sist until  the  destruction  of  the  affected  nervous  elements;  then 
the  centers  for  equilibrium  and  coordination  become  adapted  to 
the  conditions,  and  no  further  symptoms  are  noticed.  The  deaf- 
ness becomes  permanent. 

Similar  symptoms  may  be  produced  by  tumor  in  the  cerebello- 
pontal  region,  or  by  basal  meningitis.  Other  symptoms  of  menin- 
gitis or  of  tumor  should  make  the  diagnosis  fairly  easy. 

Treatment  must  be  based  upon  the  cause  of  the  attack,  and 
upon  its  severity.  The  recumbent  position  may  give  relief.  Thor- 
ough treatment  to  the  cervical  spinal  column,  with  correction  of 
whatever  lesions  may  be  found,  may  relieve,  probably  through  re- 
lieving the  congestion  in  the  vestibule.  Counterirritants  to  the  mas- 


THB  VAGUS  443 

toid  may  be  helpful.  If  the  patient  can  be  kept  fairly  comfortable 
until  the  death  of  the  neurons  concerned,  his  later  life  is  not 
affected. 

The  Glosso-pharyngeal  nerves  are  so  closely  related  to  the  other 
basal  nerves,  and  their  areas  of  distribution  are  so  thoroughly 
overlapped  by  the  distribution  of  neighboring  nerves,  that  almost 
nothing  is  known  of  their  diseases.  Disturbances  in  taste  are  due 
to  involvement  of  these  nerves,  but  individual  variations  are  com- 
mon, and  the  fact  of  disturbed  gustatory  sense  is  not  conclusive. 
Its  disease  is  probably  always  associated  with  disease  of  the 
vagus. 

The  Tenth,  Vagus,  or  Pneumogastric  nerve  has  such  intimate 
relationships  with  the  ninth,  eleventh  and  twelfth  cranial  nerves 
that  it  is  practically  impossible  to  make  exact  ante-mortem  diag- 
nosis in  cases  in  which  many  branches  of  the  vagus,  or  any  com- 
plicating factor  whatever,  are  present. 

The  vagus  is  subject  to  the  usual  causes  of  basal  meningitis 
and  increased  intracranial  pressure,  such  as  syphilis,  chronic  men- 
ingitis, toxic  influences,  and  tumors.  During  its  course  through 
the  neck  its  proximity  to  the  pulsating  carotid  modifies  the  symp- 
toms produced  by  direct  pressure  upon  the  common  sheath.  In 
passing  through  the  superior  thoracic  inlet  the  nerve  trunk  may  be 
subjected  to  pressure  by  goiter,  tumors,  aneurysm,  anterior  curve  of 
the  cervical  spinal  column,  and  other  less  frequent  factors.  Hyper- 
tension of  the  scaleni  and  other  muscles  of  the  anterior  cervical 
group  may  raise  ribs  and  clavicles  and  may  also,  by  their  swell- 
ings, diminish  the  size  of  the  thoracic  inlet  and  exert  more  or  less 
serious  pressure  upon  the  vagus-carotid-jugular  sheath.  Wounds 
and  surgical  operations  in  the  neck  may  injure  or  sever  the  vagus. 
Neuritis,  especially  diphtheritic  and  toxic,  may  affect  it  also. 

The  vagus  is  peculiar  in  being  only  very  indirectly  and  feebly 
subject  to  volitional  control,  yet  it  is,  in  all  its  branches,  very 
urgently  affected  in  emotional,  and  still  more,  hysterical,  control. 
It  may  almost  be  called  the  "hysterical  nerve." 

The  Pharyngeal  branches  are  intimately  associated  with  the 
branches  of  the  glossopharyngeal  nerves,  in  the  pharyngeal 
plexus.  Spasm  of  the  pharyngeal  muscles  is  usually  hysterical, 
"globus  hystericus."  Paralysis  of  these  muscles  causes  various 
disturbances  in  deglutition ;  when  the  soft  palate  is  paralyzed  also, 
the  food  passes  into  the  nose.  This  disease  is  usually  part  of  a 
glosso-labio-pharyngeal  paralysis,  and  is  usually  nuclear.  (See 
bulbar  paralysis.) 

The  Laryngeal  branches  are  both  sensory  and  motor.  The 
winding  of  the  left  recurrent  laryngeal  around  the  arch  of  the 
aorta  and  of  the  right  around  the  subclavian  artery,  subjects  these 
nerves  to  the  effects  of  aneurysm  of  these  vessels;  the  left  nerve 


444      *  THB  CRANIAl  NERVES 

is   also  affected  by  pressure  from  the  dilated  auricle   in   mitral 
stenosis. 

Laryngeal  spasm  is  most  frequent  in  children  (see  laryngismus 
stridulus).  It  may  occur  in  adults  as  part  of  a  general  neurosis 
of  various  types ;  in  hysteria ;  as  an  equivalent  for  migraine ;  as  a 
crisis  in  locomotor  ataxia,  and  under  other  even  more  rare  condi- 
tions. It  causes  dyspnea,  which  reaches  apparently  a  severe  stage ; 
the  accumulation  of  carbon  dioxide  finally  so  affects  the  respira- 
tory center  as  to  produce  relaxation.  Death  never  occurs  from 
asphyxia  due  to  this  alone,  though  in  organic  diseases  of  the 
nervous  system  or  the  heart,  death  may  be  precipitated  by  such 
an  attack. 

Lewyngeal  paralysis  is  usually  bulbar  and  is  generally  bilateral. 
Rarely  cerebral  lesion  may  occasion  upper  neuron  type  of  laryn- 
geal paralysis;  this  is  practically  never  limited  to  the  area  of  the 
laryngeal  muscles.  The  weakness  of  the  laryngeal  muscles  that 
comes  from  overuse,  as  in  "clergyman's  sore  throat"  or  as  part 
of  general  weakness,  must  not  be  confused  with  true  paralysis  of 
the  muscles.  In  complete  bilateral  paralysis  phonation  and  cough- 
ing are  impossible ;  respiration  is  unimpeded,  though  there  may  be 
some  harshness  of  the  respiratory  sounds,  due  to  the  relaxation 
of  the  cords,  perhaps  also  to  some  swelling  of  the  mucous  mem- 
branes. In  unilateral  complete  paralysis  the  symptoms  are 
variously  modified. 

Paralysis  of  the  abductors  permits  the  approximation  of  the 
cords  by  the  unopposed  adductors.  Various  whistling  and  strid- 
ulous  sounds  are  caused  by  the  long,  sometimes  difficult  respira- 
tory movements.  Bilateral  paralysis  of  the  abductors  may  at  any 
time  become  very  serious  from  swelling  of  the  membranes; 
asphyxia  may  be  fatal.  In  unilateral  paralysis  the  voice  is  hoarse 
and  low;  ultimately  contractures  result  in  about  the  same  condi- 
tion as  in  bilateral  paralysis. 

Paralysis  of  the  adductors  leads  to  loss  of  phonation ;  coughing 
is  normal ;  there  is  no  stridulent  tone,  and  no  dyspnea.  This  is 
usually  hysterical;  overuse  of  the  voice  may  result  in  fatigue  that 
may  be  practically  identical  with  paralysis.  Usually  recovery  is 
to  be  expected  upon  relief  of  the  etiological  factors. 

Sensory  paralysis  of  the  laryngeal  nerves  may  allow  the  food 
to  enter  the  larynx  and  trachea;  aspiration  pneumonia  or  imrne- 
diate  suffocation  may  result. 

The  Cardiac  branches.  Irritation  of  the  vagus  produces 
slower  heart  beat.  When  the  irritation  is  long  continued,  the 
action  of  the  heart  reflexes,  with  the  variations  in  blood  pressure 
thus  produced,  result  very  often  in  an  irregular  beat.  The  prox- 
imity of  the  pulsating  carotid  prevents  pressure  inhibition  of  the 


THB  VAGUS  445 

vagus,  such  as  may  occur  in  most  nerve  trunks  of  the  body. 
Cervical  lesions  affect  the  vagus  both  through  muscular  contrac- 
tion and  through  the  reflex  action  of  the  centers  in  the  upper 
cervical  cord  and  the  medulla.  When  both  right  and  left  nerves 
are  destroyed  the  outlook  is  grave;  the  condition  is  rarely  rec- 
ognized ante-mortem,  on  account  of  the  speediness  of  death.  Most 
affections  of  the  cardiac  branches  are  functional.  (See  cardiac 
neuroses.) 

The  Pulmonary  branches  are  related  with  sympathetic  branches 
and  are  distributed  to  the  blood  vessels  and  to  the  nonstriated 
muscle  fibers  of  the  br'onchioles ;  trophic  fibers  are  not  certainly 
proved.  Sensory  fibers  controlling  the  action  of  the  respiratory 
centers  are  present.  Irritation  of  these  nerves  causes  attacks  of 
asthma.  Respiratory  movements  are  influenced  by  many  factors, 
and  are  thus  of  variable  value  in  diagnosis. 

The  Gastric,  Intestinal,  and  Esophageal  branches  of  the  vagus 
have  such  intimate  relations  with  the  sympathetic  and  the  splanch- 
nic nerves,  and  the  symptoms  referable  to  these  various  nerve 
trunks  and  their  related  centers  are  so  complex,  that  it  is  difficult 
to  distinguish  between  organic  and  functional  disturbances  of  the 
different  groups.  Nausea  is  caused  by  irritation  of  the  vagus  or 
its  center;  vomiting  may  occur.  Bilateral  lesion  of  the  vagus 
causes  persistent  disturbance  of  digestion,  usually  with  vomiting 
of  bile,  sometimes  of  feces,  with  other  symptoms  of  acute  intes- 
tinal obstruction. 

Vagotony  is  the  term  applied  to  a  symptom  complex  supposed 
to  be  due  to  increased  action  of  the  vagus.  It  includes  constipa- 
tion of  the  spastic  type,  with  attacks  of  diarrhea  and  mucous 
colitis,  which  are  precipitated  by  slight  nervous  disturbances,  or 
by  drinking  hot  or  cold  water.  Pain  in  the  colon,  very  severe 
just  after  defecation,  is  often  a  prominent  symptom.  The  heart  is 
slow,  asthma  is  often  present;  variations  in  perspiration  and  in 
vasomotor  control  are  frequent.  The  treatment  is  chiefly  sympto- 
matic. Reflex  causes  of  disturbed  function  must  be  sought  and 
relieved. 

The  Spinal  Accessory,  or  eleventh  nerve  is  composed  of  two 
distinct  parts;  one  joins  the  vagus,  and  is  probably  properly  con- 
sidered as  a  part  of  that  nerve,  since  it  is  derived  from  the  vagal 
nucleus.  The  other  part  represents  a  spinal  nerve  trunk,  and  is 
derived  from  the  upper  cervical  spinal  segments.  It  is  distributed 
efficiently  only  to  the  trapezius  and  the  cleido-mastoid  muscles. 

Spasm  of  the  second  of  these,  with  or  without  associated  spasm 
of  the  first,  causes  wry  neck.  This  is  often  a  temporary  condition, 
as  in  the  wry  neck  caused  by  rheumatism  or  cold.  It  is  then 
either  due  to  disturbed  nerve  action,  or,  more  frequently,  to  a 


446  THE  CRANIAL  NERVES 

muscular  rheumatism  affecting  the  cleido-mastoid,  with  other 
neighboring  muscles.  Spasms  may  be  present  in  chorea  or  in  tics. 
Congenital  wry  neck  is  properly  a  deformity,  a  shortening  of  the 
muscle  of  the  affected  side.  It  may  begin  primarily  as  a  muscle 
spasm,  with  ultimate  shortening  of  the  contractured  muscle.  (See 
Torticollis.) 

Paralysis  of  these  muscles  causes  the  shoulder  to  droop,  and 
those  arm  movements  which  depend  upon  shoulder-girdle  fixation 
become  impossible  or  difficult.  This  type  of  paralysis  is  always  of 
the  lower  neuron  type;  upper  neuron  lesions  affecting  these  rnus- 
cles  include  other  muscles  also. 

The  most  common  causes  of  organic  disease  of  the  eleventh 
nerve  are  caries  of  the  upper  cervical  spinal  column,  meningitis, 
or  the  usual  causes  of  neuritis.  The  most  common  causes  of 
functional  disturbance  are  rheumatic,  toxic,  or  the  result  of  emo- 
tional disturbances. 

The  Hypoglossus,  or  twelfth  cranial  nerve,  is  rarely  affected 
alone.  Irritating  lesions  cause  spasm  of  the  tongue;  this  is  most 
commonly  caused  by  hysteria,  and  not  by  organic  lesion. 

Destructive  lesions  result  in  paralysis;  the  tongue  is  drawn  to 
the  affected  side,  by  unopposed  action  of  the  normal  muscles. 
Nuclear  and  infra-nuclear  lesions  cause  paralysis  with  loss  of 
reflexes  and  muscular  atrophy;  supra-nuclear  lesions  cause  loss 
of  voluntary  movement,  but  not  of  reflexes,  and  without  atrophy, 
lyittle  evil  effect  follows  this  paralysis. 


PART  VIII 
THE  DISEASES  OF  THE  SKELETAL  MUSCLES 


GENERAL  DISCUSSION 

The  skeletal  muscles  are  protected  by  their  anatomical  rela- 
tionships from  many  of  the  diseases  affecting  the  visceral  muscles. 
Very  few  of  the  primary  muscular  diseases  are  found  in  ordinary 
practice,  especially  in  this  country.  Anything  which  interferes 
markedly  with  the  innervation -or  the  circulation  of  striated  mus- 
cles may  produce  atrophy  or  weakness. 

Toxins  or  infections  of  the  muscles  cause  the  muscle  fibers  to 
lose  their  striae;  the  muscular  nuclei  may  increase  in  number; 
and  there  is  usually  a  multiplication  of  the  interstitial  connective 
tissues.  Fat  is  frequently  deposited  between  the  muscle  fibers 
under  such  conditions.  The  abiotrophic  muscular  diseases,  like 
similar  diseases  in  the  nervous  system,  appear  to  be  due  to  a 
congenital  or  hereditary  defect  of  the  germ  plasm. 

Muscles  kept  contracted  by  a  constantly  acting  stimulus  acquire 
a  peculiar  state  which  seems  intermediate  between  normal  mus-' 
cular  contraction  and  contracture.  Doubtless  the  condition  finally 
terminates  in  fibrosis.  This  constant  contraction  is  noticed  most 
frequently  in  the  muscles  of  the  deeper  layers  of  the  back,  when 
these  are  stimulated  by  nerve  impulses  reflexly  produced  by  bony 
lesions  or  by  visceral  disease.  The  muscle  becomes  stiff  on  palpa- 
tion, often  with  harder  knots  or  cords  which  are  usually  very 
hypersensitive ;  sometimes  the  entire  muscle  becomes  hypesthetic 
or  anesthetic  after  long  contraction.  Rigidity  of  the  spinal  areas 
affected  is  promoted  by  these  contractions,  especially  when  several 
spinal  segments  are  involved. 

The  affected  muscles  are  weaker  than  normal ;  they  tend  to 
recur  to  their  contracted  state  after  relaxation,  and  it  appears  very 
probable  that  they  are  responsible  for  the  perpetuation  of  bony 
lesions,  and  for  their  recurrence  after  correction.  It  is  evident 
that  normal  sensory  stimulation  does  not  arise  from  muscles  kept 
unduly  tense ;  thus,  they  are  at  least  partly  responsible  for  the 
diminished  activity  of  the  nerve  centers  of  the  corresponding 
spinal  segments.  Such  muscular  tension  is  properly  called  a  "mus- 
cular lesion." 

Bony  lesions  are  frequently  found  responsible  for  weakness 
of  individual  muscles  or  for  muscle  groups,  but  not,  so  far  as  our 
present  knowledge  goes,  for  true  muscular  disease. 

447 


CHAPTER  XLI 
DISEASES  OF  MUSCLES 

ACUTE  POLYMYOSITIS 

(Infectious  myositis) 

This  is  a  rare  disease,  probably  due  to  the  presence  of  some 
unknown  infectious  organism.  It  is  a  true  inflammatory  process, 
characterized  by  hyperemia,  swelling,  pain,  and  edema  of  the 
muscles.    Leucocytic  infiltration  is  present  in  the  muscle. 

The  muscles  of  the  arms  and  legs  first  become  hard,  swollen, 
painful  and  stiflF;  later,  the  muscles  of  the  face  and  trunk  become 
involved ;  swallowing  and  respiration  become  difficult ;  and  death 
usually  occurs  in  a  few  weeks  in  the  acute  form.  Rarely  the  acute 
form  of  the  disease  may  become  chronic  and  death  be  delayed  for 
two  or  three  years.  A  low  fever  is  usually  present  during  the 
earlier  stages. 

The  treatment  is  unsatisfactory,  on  account  of  our  ignorance 
concerning  the  true  cause  of  the  condition.  Such  treatment  as 
seems  to  be  indicated  by  the  condition  of  the  patient  at  the  time 
of  the  examination  may  be  given  as  a  palliative  measure.  The 
treatment  which  generally  increases  the  resistance  of  the  body  to 
infection  is  indicated  on  general  principles.  Rest  in  bed,  a  non- 
purin  diet,  with  very  free  water  drinking,  are  perhaps  the  most 
useful  factors  in  the  treatment. 


MYOSITIS  OSSIFICANS 

Two  forms  of  this  disease  are  known.  The  local  form  is  due  to 
irritation  of  single  muscles,  or  muscle  groups.  It  is  present  in 
horsemen  as  the  result  of  the  pressure  of  the  saddle  upon  the 
legs;  it  occasionally  affects  the  muscles  of  the  shoulders  in  men 
who  carry  heavy  burdens  upon  the  shoulders.  In  this  form  the 
muscles  affected  undergo  first  the  changes  characteristic  of  acute 
myositis,  with  marked  overgrowth  of  the  interstitial  connective 
tissue.  The  scarlike  tissue  thus  formed  undergoes  slowly  progres- 
sive calcification. 

General,  or  systemic,  myositis  ossificans  is  a  rare  disease,  char- 
acterized by  the  spontaneous  occurrence  of  bonelike  growths, 
involving  mostly  the  musculo-tendinous  areas.  The  cause  is 
unknown..  No  history  of  heredity  or  syphilis  is  present.  It  ap- 
pears usually  before  the  tenth  year  of  life. 

448 


ACUTE  POLYMYOSITIS  449 

The  muscles  affected,  usually  first  of  the  shoulder  or  pelvic 
girdle,  become  slightly  swollen,  stiff  and  painful;  a  small  hard 
lump  appears,  which  may  reach  the  size  of  an  orange ;  the  calcifica- 
tion extends  along  the  tendon  and  the  muscle,  following  the  con- 
nective tissue  trabeculae.  The  muscle  does  not  become  paralyzed, 
but  movement  of  the  neighboring  joint  becomes  impossible  on 
account  of  the  ossification  of  the  tendons.  In  this  type  the  tumors 
resemble  newly  formed  bone. 

It  is  rare  for  life  to  be  prolonged  beyond  the  twentieth  year. 
Death  occurs  either  from  some  intercurrent  disease,  or  as  the 
result  of  suffocation  due  to  the  involvement ,  of  the  respiratory 
muscles. 

SECONDARY  MUSCULAR  DISEASES 

Rheumatic  Myositis.  Rheumatic  myositis  is  an  inflammation 
of  the  muscles  due  to  the  bacteria  which  cause  other  rheumatic 
diseases,  (q.  v.) 

Suppurative  Myositis.  Suppurative  myositis,  or  muscular 
abscess,  may  be  due  either  to  the  infection  of  a  wound  or  to 
septicemia.  The  diagnosis  of  this  condition  rests  upon  the  pain, 
leucocytosis,  and  other  symptoms  of  pus  formation.  The  treat- 
ment is  surgical. 

Gouty  myositis  is  a  painful  chronic  inflammation  of  the  muscles 
associated  with  systemic  gout,  (q.  v.) 

Trichiniasis.  Trichiniasis  (q.  v.)  often  involves  the  muscles. 
The  diagnosis  rests  upon  the  history  of  pork  eating,  the  character 
of  the  pain,  marked  eosinophilia,  and  sometimes  a  microscopical 
examination  of  an  excised  bit  of  muscle.  The  treatment  is  sym- 
tomatic,  and  the  prognosis  may  be  very  serious. 

Paralysis  of  the  Striated  Muscles  without  Atrophy  is  due  to 
some  lesion  of  the  upper  neuron  system. 

Paralysis,  or  Weakness,  of  the  Striated  Muscles  with  Atrophy 

may  be  due  to  injury  to  the  muscle  itself  as  in  the  primary  muscu- 
lar diseases,  to  diseases  affecting  the  motor  end-plates,  to  disease 
of  the  nerve  trunk,  or  to  disease  of  the  anterior  horns  of  the  spinal 
cord.  These  conditions  are  discussed  in  connection  with  the  dis- 
eases of  the  nervous  system. 

Arthritic  Muscular  Atrophy.  After  the  occurrence  of  arthritis 
anywhere  in  the  body,  the  muscles  which  move  the  affected  joints 
undergo  a  variable  amount  of  atrophy.  This  type  of  atrophy  is  not 
associated  with  the  presence  of  any  hypertrophic  fibers  and  with 
only  slight  increase  in  the  interstitial  tissue. 

It  seems  to  be  due  to  some  reflex  trophic  effect,  resulting  from 
the  irritation  of  the  sensory  nerves  distributed  to  the  articular 


450  THE  SKELETAL  MUSCLES 

surfaces,  with  the  subsidence  of  the  inflammation  in  the  joint. 
The  muscles  may  regain  their  normal  size  and  strength.  Occa- 
sionally the  atrophy  persists  and  secondary  contractions  occur 
which  may  resemble  those  found  in  anterior  poliomyelitis. 

THE  MUSCULAR  DYSTROPHIES 

This  group  of  diseases  affecting  the  skeletal  muscles  includes 
several  subdivisions,  all  of  which  are  characterized  by  the  impor- 
tance of  heredity  in  their  etiology;  by  the  appearance  of  the  dis- 
ease before  puberty;  as  a  rule,  by  the  fact  that  a  certain  amount 
of  hypertrophy  is  associated  with  the  atrophy^  and  by  the  lack  of 
recognizable  nerve  lesions. 

No  treatment  appears  to  be  of  any  value  in  preventing  the 
ultimate  fatal  outcome,  though  in  some  very  mild  cases  the  after- 
history  of  the  patient  may  not  be  seriously  modified  by  the  occur- 
rence of  this  disease  in  early  life. 

Myotonia  Congenita  (Thomsen's  disease).  This  is  a  familial 
disease  of  the  muscles,  characterized  by  the  following  symptoms: 
When  the  patient  attempts  any  movement,  after  a  period  of  rest, 
the  muscles  affected  contract  strongly  and  do  not  relax  for  a  con- 
siderable interval ;  the  next  contraction  is  followed  by  a  somewhat 
diminished  contracture  period;  the  third,  by  a  still  less  prolonged 
tonic  contraction;  until  finally  the  patient  becomes  able  to  per- 
form the  motion  which  he  had  first  decided  upon.  *  This  series  of 
events  is  repeated  whenever  the  patient  endeavors  to  begin  any 
complex  action,  as  in  walking.  Sometimes  the  attack  is  so  severe 
as  to  throw  him  to  the  ground,  more  frequently  there  is  merely 
difficulty  in  getting  started. 

The  visceral  muscles  are  never  involved.  Mental  disturbances 
may  be  present.  Reflexes  are  slightly  modified  or  unchanged. 
Muscular  weakness  is  noticeable,  though  the  muscles  may  be 
normal  or  considerably  increased  in  size.  Electrical  reactions  are 
changed  (myotonic  reaction). 

A  similar  atypical  disease  may  occur  without  hereditary  basis; 
its  cause  is  unknown. 

The  attacks  are  made  worse  by  exposure  to  cold  and  by  emo- 
tional excitement.  Treatment  is  practically  useless.  It  does  not 
greatly  shorten  life,  but  recovery  is  not  to  be  expected. 

Pseudohypertrophic  Muscular  Atrophy,  or  pseudomuscular 
hypertrophy  (Duchenne)  is  a  form  of  the  disease  which  is  char- 
acterized by  its  first  affecting  the  muscles  of  the  calves  of  the  legs. 
This  comes  on  rather  slowly  as  a  hypertrophy  and  may  at  first 
be  considered  evidence  of  the  child's  excellent  health.  There  is 
usually  a  lordosis,  which  exaggerates  the  deformity.  The  mus- 
cles are  very  weak,  even  when  the  size  is  much  greater  than  nor- 


MUSCULAR  DYSTROPHIES  451 

mal.     Other  muscles  of  the  body,  including  the  trunk  and  res- 
piratory muscles,  become  affected  and  death  occurs  from  cachexia. 
Occasionally  this  form  of  muscular  atrophy  is  associated  with 
epileptic  attacks  and  with  mental  defect. 

Leyden-Moebius  type.  In  this  form  of  muscular  atrophy  the 
hypertrophy  is  not  apparent,  and  the  hereditary  influence  is  even 
more  marked.     Otherwise,  the  disease  is  like  that  just  described. 

The  Scapulohumeral  type  has  been  described  by  Erb.  It  comes 
on  later  in  life,  even  up  to  the  age  of  twenty,  and  affects  first  the 
muscles  of  the  shoulder  girdle. 

A  peculiar  wing-like  position  of  the  scapulae  results  from  the 
atrophy  of  these  muscles.  The  disease  extends  to  the  leg  and 
trunk  muscles,  and  death  occurs  as  already  mentioned. 

Facioscapulohumeral  type  (Dejerine-Landouzy).  This  dis- 
ease is  especially  characterized  by  its  onset  in  about  the  third  or 
fourth  year,  affecting  first  the  muscles  of  the  face.  The  disease 
affects  then  the  shoulder,  leg  and  trunk  muscles.  This  form  of 
the  disease  is  very  slow  in  its  progress  and  patients  may  live  to 
be  thirty  or  forty  years  old. 

Atrophic  Myotonia.  This  is  a  rare  disease  characterized  by 
abnormally  slow  relaxation  of  certain  muscle  groups  after  con- 
traction, and  by  the  occurrence  of  atrophy  in  the  muscles  affected. 

Oppenheim'g  Myotonia.  In  this  disease  the  muscles  undergo 
flaccid  paralysis  with  loss  of  the  reflexes.  It  does  not  shorten  life 
and  is  incurable.  The  muscles  atrophy  and  the  patient  becomes 
helpless.  Massage  of  the  affected  muscles  and  electrical  stimula- 
tion seem  to  delay  somewhat  the  course  of  the  disease.  Some 
relation  between  the  thymus  gland  and  this  disease  has  been 
suggested. 

Myasthenia  Gravis.  This  is  a  rare  disease  of  unknown  etiol- 
ogy. The  muscles  of  mastication,  speech  and  deglutition  are  in- 
volved, and  also  the  extrinsic  eye  muscles.  The  disease  is  char- 
acterized by  very  rapid  fatigue,  which  is  inherent  in  the  muscle 
itself,  rather  than  in  the  nervous  control.  Dyspnea,  dysphagia, 
and  ptosis  of  the  eyelid  are  noticeable  symptoms.  Death  occurs 
from  exhaustion,  or  the  patient  may  be  strangled  while  trying  to 
swallow. 

Dysbasia  Lordoca  Progressiva  (Tortipelvis).  This  is  a  disease 
peculiar  to  Jews,  which  appears  in  children  and  young  adults. 
Muscular  spasms  of  the  lumbar  and  pelvic  region  cause  a  deformity 
of  this  part  of  the  body.  There  is  marked  lordosis  of  the  dorso- 
lumbar  spinal  column.  There  are  no  signs  of  organic  disease  of 
the  nervous  or  osseous  systems.  The  terms  "monkey"  gait"  or 
"dromedary  gait"  have  been  applied  to  this  condition. 


452  THE  SKELETAL  MUSCLES 

FUNCTIONAL  MOTOR  DISTURBANCES 

The  different  varieties  of  chorea,  spasm,  tic  and  tremor  are 
generally  considered  functional  or  idiopathic.  It  is  needless  to 
say  that  the  use  of  these  terms  is  merely  a  confession  of  our 
ignorance  of  the  structural  or  biochemical  changes  which  must 
necessarily  be  present  in  every  disease.  The  term  spasm  is 
applied  to  those  muscular  contractions  which  result  from  some 
irritation  in  the  lower  reflex  arc.  True  spasm  is  involuntary  and 
is  not  to  be  controlled  by  any  process  of  education.  The  chorei- 
form movements  resemble,  to  so  great  an  extent,  the  movements 
resulting  from  pathological  changes  in  the  basal  ganglia,  especially 
in  the.  lenticular  nucleus,  that  it  may  be  granted  that  these 
movements  are  due  to  the  irritation  somewhere  in  the  higher 
reflex  arc,  including  perhaps  the  pontine  centers  as  well  as  the 
basal  ganglia.  Tic,  or,  as  it  is  sometimes  called,  habit  spasm, 
results  from  the  repetition  of  complicated  movements.  These  are 
involuntary  in  the  beginning  and  are  often  initiated  under  some 
emotional  strain.  Reeducation  is  often  efficient  in  dealing  with 
these  cases.  The  seat  of  the  disturbed  function  in  the  tic  is 
probably  in  the  deeper  layers  of  the  cerebral  cortex  where  other 
habitual  unconscious  actions  are  controlled. 

All  of  the  functional  motor  neuroses  having  a  certain  degree 
of  hereditary  taint  rest  upon  the  presence  of  a  neuropathic  consti- 
tution. In  all  of  them,  the  treatment  must  include  the  measures 
necessary  to  secure  good  nutrition,  good  elimination,  rest  and 
wholesome,  sane,  hygienic  life  for  the  patient. 

Primary  Athetosis.  This  is  a  rare  functional  disease,  charac- 
terized by  the  occurrence  of  slow  athetoid  movements  of  the 
hands.  It  occurs  in  late  middle  life  or  old  age  and  is  not  asso- 
ciated with  mental  deterioration.  Only  after  organic  lesions  of 
the  brain  and  especially  of  the  corpora  striata  and  optic  thalamus 
have  been  eliminated  can  a  diagnosis  of  prirnary  athetosis  be  made. 
No  treatment  affects  the  course  of  the  disease.  It  persists  through- 
out life,  which  it  does  not  seem  to  shorten. 

Senile  Tremor.  This  occurs  in  old  people  frequently  at  the 
age  of  70  or  thereabouts.  The  fingers  and  thumb  are  usually  held 
straight,  at  right  angles  to  the  hands,  and  the  tremor  involves 
both  fingers  and  hand  and  occasionally  the  neck  muscles  are 
•affected,  so  that  the  patient  constantly  nods  his  head.  The  condi- 
tion is  not  associated  with  any  mental  peculiarity  and  the  only 
pathological  conditions  are  those  characteristic  of  old  age.  No 
harm  results  from  the  condition  and  no  treatment  is  of  the  least 
avail  in  controlling  it. 

Toxic  Tremor.  Alcohol  or  tobacco,  lead,  mercury  and  certain 
other  metallic  poisons  or  the  organic  poisons  or  autointoxication 
may  all  act  upon  the  nerve  centers  as  to  produce,  a  rather  irregular 


PERIODIC  PARALYSIS  453 

tremor.     The   condition   disappears   with  the   elimination  of  the 
poison. 

PERIODIC  PARALYSIS 

(Family  periodic  paralysis) 

This  is  a  family  disease  of  rare  occurrence  in  this  country, 
characterized  by  the  occurrence  of  almost  or  quite  total  paralysis, 
from  which  the  patient  rather  speedily  apparently  recovers. 

Etiology.  The  disease  is  always  hereditary.  It  appears  to 
follow  Mendel's  law,  though  the  number  of  cases  on  record  is  not 
sufificient  to  prove  the  law  by  exact  numbers. 

The  individual  attacks  may  occur  without  recognizable  cause, 
but  they  are  frequently  precipitated  by  muscular  exertion  or  by 
overeating. 

Pathology.  Almost  no  structural  changes  are  constantly  present.  An 
examination  of  the  muscles  sometimes  shows  slight  vacuolization  with  occa- 
sionally a  hypertrophied  cell.  In  some  cases  no  changes  in  either  the  muscles 
or  the  central  nervous  system  are  to  be  found  upon  the  most  careful  examination. 

The  diminished  excretion  of  the  calcium  and  magnesium  salts  in  the  urine 
seems  to  be  fairly  constant.  It  has  been  suggested  that  the  paralysis  is  due  to 
the  excess  of  these  salts  thus  retained  within  the  blood  which  inhibits  the  action 
of  the  nerve  and  muscle  cells. 

Diagnosis.  The  symptoms  and  history  are  fairly  typical.  The 
family  history  shows  the  hereditary  taint,  while  the  history  of 
previous  attacks  with  recovery  should  make  the  diagnosis  certain. 
There  are  prodromes  usually  of  a  vague  discomfort.  The  patient 
goes  to  sleep  and  awakens  completely  paralyzed.  Occasionally 
the  paralysis  is  not  quite  complete,  but  it  usually  involves  all  four 
limbs.  Speech,  the  sphincters,  the  respiratory  muscles  and  deglu- 
tition are  not  affected.  The  reflexes  are  clearly  diminished  or 
may  be  absent.  The  muscles  do  not  usually  contract  in  answer  to 
the  electric  current.  The  heart  is  frequently  found  dilated  on 
examination  during  an  attack.  This  disappears  with  recovery. 
Examination  of  the  urine  shows  some  albumin,  some  blood  and 
occasionally  some  hemoglobin. 

The  attack  lasts  a  few  hours  to  a  few  days.  Then  a  very  pro- 
found perspiration  occurs,  followed  by  weakness,  sometimes  sleep 
and  a  gradual  recovery.  During  convalescence  the  muscles  are 
very  weak  and  strength  is  regained  only  after  some  days  or  weeks 
of  gradual  improvement. 

Treatment.  The  treatment  is  devoted  to  preventing  attacks. 
Overeating,  constipation,  undue  muscular  exertion,  are  to  be 
avoided.  The  correction  of  such  bony  lesions  as  may  be  found 
on  examination  should  be  of  value  in  securing  good  nutrition  and 
good  elimination. 

Prognosis.  The  prognosis  is  bad  for  complete  recovery;  is 
very  good  for  recovery  from  any  attack,  and  is  bad  for  the  descend- 
ents  of  the  individual.     Marriage  should  be  prohibited. 


PART  IX 
THE  INFECTIOUS  DISEASES 


GENERAL  DISCUSSION 

This  group  includes  a  number  of  diseases  which  have  many- 
factors  of  etiology  and  treatment  in  common.  All  of  them  are 
infectious  and  most  of  them  are  due  to  bacteria.  It  is  quite  pos- 
sible that  protozoan  agents  may  be  present  in  some  cases.  All 
owe  their  presence  to  some  form  of  uncleanliness.  They  are  a 
disgrace  to  modern  civilization.  Children,  with  their  gregarious 
habits  in  regard  to  the  use  of  pencils  and  chewing  gum,  transmit 
disease  germs  from  one  to  another  with  truly  remarkable  celerity. 
Even  with  such  facilities  for  the  transmission  of  infectious  agents 
comparatively  few  children  contract  these  diseases,  even  in  an 
epidemic.  This  fact  is  due  to  the  immunity  of  the  resistant  chil- 
dren. 

Immunity  depends  upon  many  factors.  Certain  diseases  confer 
immunity  to  succeeding  attacks^Uiis  is  the  basis  for  certain  types 
of  so-called  preventive  medicine.  The  blood  serum  and  the  white 
blood  cells  appear  to  be  actively  bactericidal.  The  skin  and  the 
membranes  lining  the  body  cavities  are  normally  impermeable  to 
bacterial  invasion.  (A  very  few  pathogenic  bacteria  are  persistent 
and  able  to  live  upon  normal  body  tissues  and  fluids.) 

The  skin  and  mucous  membranes  resist  bacteria  only  so  long 
as  they  are  intact.  Diseased  tonsils,  decayed  teeth  and  abrasions 
are  important  gateways  for  the  entrance  of  pathogenic  bacteria 
into  the  body.  The  value  of  the  blood  as  a  factor  in  immunity  is 
diminished  when  it  does  not  circulate  freely  or  when  it  contains 
certain  toxic  elements. 

The  lymphoid  tissues  are  important  agents  in  immunity.  Nor- 
mal tonsils  are  included  with  the  spleen  and  lymph  nodes. 

The  place  of  bony  lesions  in  lowering  immuni.ty  depends  upon 
the  relationships  already  stated.  Lesions  of  the  upper  thoracic 
and  cervical  regions  predispose  to  infection  of  the  mouth  and  the 
upper  respiratory  tract.  By  lowering  the  -resistance  of  this  area 
of  the  body  infectious  agents  may  gain  entrance  into  the  body 
and  produce  systemic  disease.  This  is  especially  the  case  in 
scarlet  fever,  measles,  diphtheria,  and  a  number  of  other  acute 
infections.  The  fifth  thoracic  to  the  first  lumbar  spinal  segments 
control  the  action  of  the  liver,  spleen,  pancreas  and  the  gastro- 
intestinal tract.  "A  rigid  lower  thoracic  spine  is  an  important 
factor  in  lowering  immunity  and  vigorous  treatment  to  this  spinal 

454 


GENERAL  DISCUSSION  455 

area  to  the  liver  and  spleen  raises  the  body  resistance." — C.  A. 
Whiting. 

General  immunity  is  lowered  through  poor  nutrition,  the  reten- 
tion of  bodily  waste,  reduced  alkalinity  of  the  blood,  fatigue  and 
overwork,  lack  of  sleep,  lack  of  exercise  and  of  fresh  air,  disturbed 
digestion,  harmful  emotions,  especially  fear,  and  the  after-eflfects 
of  many  drugs,  including  serums  used  in  therapy.  Almost  any 
one  of  the  acute  infections  lessens  resistance  to  other  acute  infec- 
tions and  to  tuberculosis. 

Treatment.  Any  child  who  is  sick  should  be  separated  from 
other  children  until  the  noninfectious  nature  of  his  malady  is 
evident.  Especially  during  an  epidemic  no  sick  child  should  be 
allowed  to  be  with  other  children.  The  stringency  and  length 
of  the  time  of  quarantine  depends  on  the  nature  of  the  disease 
after  diagnosis  becomes  possible.  The  prodromal  symptoms  are 
very  much  alike  for  all  the  exantheniatous  diseases ;  therefore  it  is 
not  possible  to  make  a  certain  diagnosis  until  after  the  disease 
is  easily  transmissible.  During  this  stage  the  treatment  should 
be  thorough.  The  entire  spinal  column  and  the  ribs  should 
be  examined,  and  all  lesions,  bony,  muscular,  or  other,  corrected. 
Solid  food  should  be  stopped  immediately.  Fruit  juices  and  plenty 
of  water  should  be  freely  given.  If  the  child  is  yery  hungry  he 
may  be  allowed  to  eat  raw  apples,  lettuce  or  other  cellulose  foods. 
Berries  with  seeds,  starch,  sugar,  meat,  eggs  are  to  be  denied.  If 
either  diarrhea  or  constipation  is  present  an  enema  is  to  be  given. 
Many  doctors  advise  the  enema  of  normal  salt  solution  as  a  part 
of  the  routine  procedure  in  all  cases.  The  child  should  be  kept 
in  a  warm,  well-ventilated  room  and  be  dressed  very  lightly.  He 
should  be  put  to  bed  as  soon  as  the  temperature  goes  above  100°. 
He  may  play  quietly,  playthings  must  be  burned  upon  his  recovery. 
All  rugs,  hangings,  etc.,  should  -either  be  removed  or  should  be 
such  as  can  be  thoroughly  boiled  after  the  child  has  recovered. 
Pictures  should  be  removed  from  the  room  or  should  be  burned 
later.  During  convalescence  books,  pictures  and  inexpensive  toys 
should  be  provided  which  can  keep  him  biisy  and  happy  and  can 
be  burned  at  the  termination  of  quarantine. 

The  fever  can  usually  be  lowered  by  a  few  minutes'  steady 
pressure  between  the  transverse  processes  of  the  eighth  to  the 
eleventh  thoracic  vertebrae  or  over  the  suboccipital  triangles.  •  This 
pressure  should  be  given  after  the  ordinary  treatment.  In  the 
intervals  of  treatment,  cool  baths  lower  the  temperature.  The 
patient  may  be  placed  in  the  tub  of  water  at  about  the  body  tem- 
perature and  cold  water  added  to  about  80°.  The  patient  may 
lie  in  this  bath  from  two  minutes  to  thirty  minutes,  according  to 
his  comfort  and  the  effect  produced  upon  the  body  temperature. 
A  sponge  bath  is  better  under  many  circumstances.     This  should 


456  THB  INFECTIOUS  DISEASES 

be  slowly  given  with  water  at  or  slightly  below  the  temperature 
of  the  body.  Only  a  small  area  of  the  body  should  be  exposed 
unless  the  temperature  of  the  room  is  high. 

The  odor  associated  with  exanthematous  diseases  can  be  some- 
what relieved  by  adding  a  few  drops  of  carbolic .  acid,  creolin, 
soda  or  borax  to  the  bath  water.  Plentiful  ventilation  is  impor- 
tant.   An  open  ammonia  bottle  or  smelling  salts  may  give  relief. 

The  itching  and  burning  of  the  skin  can  be  relieved  by  the 
addition  of  the  substances  already  mentioned  to  the  bath  water, 
and  by  ointments  of  cold  cream,  white  vaseline,  etc.,  to  which 
may  be  added  talcum  powder,  starch,  small  amounts  of  soda  or 
boric  acid,  zinc  oxide.  Powders  should  be  used  over  moist  or 
weeping  surfaces.  These  may  be  of  browned  flour,  corn  starch, 
talcum,  or  any  other  smooth  powder.  To  any  of  these  may  be 
added  small  amounts  of  boracic  acid  or  soda.  Lotions  may  be 
applied  with  a  soft  cloth.  Strips  of  gauze  may  be  soaked  in  these 
and  laid  over  the  areas  of  greatest  painfulness.  Lotions  are  made 
of  water  with  a  little  alcohol  or  glycerine  to  which  is  added  a 
small  amount  of  carbolic  acid,  creolin,  zinc  oxide,  powdered  cala- 
mine or  any  other  slightly  antiseptic  or  bland  soothing  constituent. 
Any  lotion  which  does  not  injure  the  skin  and  which  feels  good 
may  be  used  for  this  purpose. 

Most  of  the  exanthematous  diseases  have  a  tendency  to  infect 
the  conjunctivae  and  thus  lead  to  serious  eye  troubles.  It  is  diffi- 
cult to  avoid  light  and  also  to  have  suitable  ventilation  in  the 
room.  Ventilation  is  of  urgent  importance.  It  is  better  to  shade 
the  eyes  with  dark  glasses  or  in  some  other  way  and  to  have 
good  ventilation  than  to  darken  the  room  at  the  expense  of  fresh 
air. 

The  patient  should  receive  thorough  osteopathic  treatment 
twice  each  day  in  the  beginning  of  the  disease,  then  once  each 
day  until  convalescence  is  established.  He  should  receive  careful 
examination  after  recovery  is  complete  in  order  that  any  sequel 
may  be  speedily  recognized  and  treated. 

After  the  fever  goes  down  the  patient  is  usually  very  hungry. 
His  diet  should  be  largely  of  fruit  and  vegetables  with  milk,  eggs, 
broths,  according  to  his  age  and  general  habits.  Too  speedy  a 
return  to  the  mixed  diet  may  result  in  digestive  disturbances.  Too 
much  meat  or  other  concentrated  food  may  add  to  the  danger  of 
kidney  disturbances.  Too  speedy  a  return  to  ordinary  activity 
may  throw  too  great  a  burden  upon  the  heart  and  permanent 
valvular  injury  may  result.  Deficient  ventilation  during  course 
of  the  disease  and  carelessness  in  clothing  or  any  exposure  to  the 
Weather  during  convalescence  increases  the  danger  of  pulmonary 
complications.  It  is  much  better  that  convalescence  be  prolonged 
a  few  days  than  that  permanent  heart,  kidney  or  pulmonary  dis- 
eases should  be  allowed  to  occur. 


GENERAL  DISCUSSION  457 

"To  correct  bony  lesions  in  acute  diseases,  the  physician  must  take  time  and 
care,  as  the  patient  is  suffering  and  not  in  a  mood  to  be  handled  quickly  or 
roughly.  The  correction  of  the  bony  lesions  is  not  so  difficult  when  the  condi- 
tion and  position  of  the  abnormal  structure  are  clear  in  the  physician's  mind. 
When  the  lesion  is  corrected  with  the  proper  ease,  the  physician  will  feel  the 
movements  of  the  abnormal  structure  slide  or  slip  into  place  so  easily  that  it  is 
ofttimes  surprising. 

"The  question  might  arise:  'Is  it  safe  to  correct  a  bony  lesion  in  a  severe 
acute  disease  when  the  patient  is  suffering,  temperature  high,  and  all  things  point 
to  a  severe  toxic  condition,  as  the  system  is  under  a  severe  strain  due  to  accumu- 
,  lation  of  the  toxic  poisons?'  One  thing  we  need  in  a  case  like  this  would  be 
harmony,  not  only  of  structure,  but  normal  physiological  functioning  as  well. 
Therefore,  let  us  correct  the  lesion.  We  may  have  to  relax  the  unequal 
muscular  contraction  which  not  only  tends  to  maintain  the  lesion,  but  also 
produces  a  tension  which  interferes  with  the  normal  nerve  forces  as  well  as 
the  blood  and  lymphatic  system.  The  object  is  to  procure  normal  action  and 
function  of  structure  as  well  as  to  assist  nature  in  producing  a  normal  physio- 
logical action.  The  amount,  length,  and  technique  of  your  treatment  must  be 
determined  by  the  condition  of  the  patient." — E.  R.  Proctor. 

Prophylaxis.  If  every  child  who  is  sick  could  be  iminediately 
isolated  from  other  children  until  the  diagnosis  is  made  it  would 
go  a  long  way  to  stop  the  spread  of  contagious  diseases.  Children 
at  school  must  be  taught  to  keep  things  out  of  their  mouths  and 
to  wash  their  hands  before  eating.  This  is  a  hard  task.  The  old 
idea  that  children  must  at  some  time  have  the  diseases  called 
"children's"  is  a  dangerous  fallacy  and  one  which  is  responsible 
for.  many  deaths  and  a  very  great  number  of  chronic  invalids. 
Children  should  be  protected  from  even  the  mildest  of  these 
diseases  very  carefully.  Every  one  leaves  a  gate  open  for  its  suc- 
cessor and  tuberculosis  is  usually  ready  to  enter  at  any  gate.  The 
typical  course  of  the  disease  as  generally  described  is  greatly  modi- 
fied by  early,  frequent  and  vigorous  treatment  which  always 
should  include  the  increased  mobility  of  the  lower  thoracic  spine 
and  raising  of  the  lower  ribs.  Other  treatment  depends  upon  the 
conditions  as  found  at  examination,  and  should  include  correction 
of  vertebral  and  costal  subluxations,  as  well  as  of  other  structural 
perversions  wherever  possible.  In  every  case  the  urine  should  be 
tested  for  albumin,  sugar  and  the  microscopical  findings  every  few 
days.  The  heart  should  be  watched  during  every  acute  disease. 
With  the  first  appearance  of  albumin  or  casts  or  kidney  epithelium 
in  the  urine  the  treatment  for  acute  nephritis  should  be  begun. 
With  the  first  sign  of  cardiac  complications  treatment  for  peri- 
cardial and  endocardial  diseases  should  be  added  to  that  already 
described  for  exanthematous.  In  this  way  the  usual  sequelae  may 
be  avoided. 

The  most  common  diseases  due  to  bacilli  are  tuberculosis  and 
leprosy,  due  to  acid-fast  bacilli ;  typhoid  and  typhus,  affecting 
chiefly  the  intestinal  tract ;  influenza,  pertussis  and  diphtheria, 
affecting  chiefly  the  respiratory  and  pharyngeal  areas.  The  dis- 
eases due  to  cocci  include  pneumonia,  meningitis,  infantile  paral- 


458  THB  INFECTIOUS  DISEASES 

ysis,  erysipelas  and  rheumatism.     Spirochaetes  are  responsible  for 
relapsing  fever  and  syphilis. 

Diseases  which  are  usually  contracted  from  animal  associates 
include  plague,  hydrophobia,  tetanus,  and  others  less  frequently. 
Many  of  the  most  serious  of  the  infectious  diseases  are  due  to 
agents  not  yet  recognized.  Mallory's  studies  of  scarlet  fever  should 
be  mentioned.  Recent  development  of  routes  of  travel,  which  no 
doubt  will  become  freely  accessible  at  the  close  of  the  war,  render 
the  tropical  diseases  of  greater  interest  than  heretofore.  The  proto-, 
zoan  diseases  are  of  especial  interest  because  of  their  frequency  and 
malignancy  in  tropical  countries  and  the  possibility  of  their  becom- 
ing acclimated  among  us. 


.     CHAPTER  XLII 
TUBERCULOSIS 

Tuberculosis  is  an  acute  and  chronic  infectious  and  contagious 
disease  caused  by  the  bacillus  of  tuberculosis,  characterized  ana- 
tomically by  the  formation  of  nodular  bodies  or  diffuse  infiltra- 
tions, and  clinically  by  symptomatology  varying  with  the  tissues 
or  organs  involved. 

Etiology.  The  essential  immediate  cause  of  the  disease  is  the 
tubercle  bacillus.  This  organism,  almost  omnipresent,  is  rather 
more  plentiful  in  the  northern  latitudes. 

The  most  important  predisposing  factor  is  the  bony,  muscular, 
or  ligamentous  lesion.  Practically  every  person  who  suffers  from 
any  tubercular  infection  has  diminished  flexibility  of  the  lower 
thoracic  spinal  column.  The  nature  of  the  lesion  varies  as  does 
the  tubercular  process,  but  the  most  frequent  condition  is  the 
characteristic  straight  spine,  infantile  chest  and  flat  interscapular 
region  with  drooping  and  immobile  ribs. 

"The  spinal  outline  characteristic  of  tuberculosis  and  of  the  pretubercular 
stages  presents  the  following  peculiarities :  The  cervical  spine  presents  various 
abnormalities,  usually  lesions  involving  single  vertebrae  and  associated  witlj 
irregular  muscular  tensions.  The  upper  thoracic  spine  is  anterior,  the  ribs 
drooping  and  rather  more  freely  movable  than  normal;  the  vertebral  articula- 
tions are  less  movable  than  normal ;  the  tissues  in  the  neighborhood  of  the  upper 
two  or  three  dorsal  spines  are  abnormally  sensitive  and  the  muscles  innervated 
from  these  segments  are  contracted  irregularly  when  the  disease  involves  the 
apices.  The  lower  interscapular  region  is  found  sensitive  and  these  muscles  are 
contracted  when  the  lower  lobes  of  the  lung  are  involved,  and  the  location  of 
these  sensitive  ar€as  may  be  employed  in  the  localization  ot  the  lung  area 
infected.  .....  ^ 

"In  every  case  recorded  in  this  clinic,  lesions  involving  the  area  of  the  origin 
of  the  upper  and  middle  splanchnic  nerves  have  been  found.  The  typical 
tuberculosis  spine  must  include  lesions  of  the  lower  dorsal  area.  Probably  these 
lesions  are  predisposing  factors  in  tuberculosis,  partly  because^  of  the  effects 
produced  upon  nutrition  thereby,  but  doubtless  the  lack  of  the  normal  mobility 
of  this  part  of  the  spine  prevents  the  normal  stimulation  of  the  liver,  the  spleen, 
perhaps  the  pancreas,  thus  the  normal  opsonic  index  is  lost,  and  immunity 
broken.  The  treatment  of  tubercular  cases  should  include  careful  attention  to 
the  splanchnic  area,  the  maintenance  of  the  normal  mobility  and  structural  rela- 
tionship of  the  entire  spinal  column,  and  such  stimulating-  movements  to  the 
ninth  and  tenth  thoracic  neighborhood  as  is  indicated  in  each  individual  case." — 
C.  A.  Whiting. 

The  immunity  lowered  and  the  bacilli  within  the  body,  the 
area  ultimately  affected  depends  at  least  to  some  extent  upon  the 
existence  of  the  bony  lesions  and  their  effect  upon  the  circulation 
of  the  blood  and  the  nutritive  condition  of  the  different  parts  of 
the  body. 

459 


460  DISEASES  DUE  TO  BACILLI 

Lesions  responsible  for  the  hospitality  of  certain  tissues  to 
tubercular  invasion  vary  according  to  the  locality  affected. 
Lesions  of  the  upper  thoracic  spine  and  upper  ribs  are  present 
when  the  first  injury  is  to  the  upper  lobes  of  the  lungs,  as  is  so 
often  the  case.  Lesions  of  the  midthoracic  region  are  associated 
with  injury  to  the  middle  and  lower  lobes  of  the  lungs.  Laryngeal 
tuberculosis  is  more  frequent  in  those  who. -have  also  lesions  of 
the  cervical  vertebrae,  and  contractions  of  the  cervical  muscles,  as 
well  as  lesions  of  the  upper  thoracic  vertebrae. 

Intestinal  tuberculosis  is  associated  with  lesions  of  the  lower 
thoracic  spine,  as  is  tuberculosis  in  almost  any  part  of  the  body; 
in  this  case  the  general  lowering  of  the  bodily  resistance  is  asso- 
ciated with  the  specific  area  involved.  Why  it  is  that  the  intestinal 
tract  so  often  escapes  is  not  easy  to  determine. 

Kidney  lesions  are  associated  with  disturbances  in  the  ver- 
tebrae and  neighboring  tissues  of  the  eleventh  and  twelfth  thoracic 
segments,  from  which  arise  the  vasomotor  nerves  to  the  kidneys, 
and  the  secretory  nerves  to  the  suprarenals.  So  it  is  everywhere 
— in  almost  every  case  efficient  factors  are  usually  found  which 
are  more  or  less  responsible  for  the  presence  of  the  disease  in  the 
organs  affected.  Naturally,  the  correction  of  these  lesions  as 
found  is  important;  naturally,  also,  this  correction  must  be  made 
in  such  a  manner  as  to  prevent  injury  to  the  tissues  already  so 
seriously  diseased. 

Bad  air,  poor  nutrition,  lack  of  sunshine  and  exercise  are  also 
most  important  predisposing  causes. 

"It  is  a  well-known  fact  if  there  were  no  tubercle  bacilli  there  would  be  no 
tuberculosis;  also  if  there  be  no  suitable  soil  there  would  be  no  tuberculosis. 

"The  fact  still  remains  that  humanity  has  not  yet  become  civilized  to  the 
point  of  cleanliness,  and  so  long  as  part  of  the  human  race  persists  in  living  in 
filth  and  spreading  it  broadcast  human  beings  will  pay  the  penalty  with  a  wrecked 
body  and  too  often  death  from  tuberculosis." — W.  J.  Hayden. 

No  age  is  free  from  the  disease,  though  it  attacks  the  young 
rather  more  frequently  than  the  old.  In  young  subjects  the  bones 
and  bronchial  lymphatics  are  most  liable  to  be  invaded.  From 
puberty  to  middle  age  the  disease  attacks  the  lungs  most  fre- 
quently, while  in  old  age  the  intestines  are  rather  more  frequently 
attacked. 

The  sexes  are  about  equally  affected  throughout  life.  Preg- 
nancy is  a  cause  of  acute  exacerbation  of  the  disease,  but  probably 
not  of  its  first  appearance.  No  races  seem  to  be  exempt.  Negroes 
are  very  susceptible.  Its  ravages  are  especially  severe  among 
savages  who  have  become  sufficiently  civilized  to  dwell  in  houses. 
Jews  are  frequently  supposed  to  be  almost  exempt,  but  in  large 
cities  where  Jews  of  the  poorer  class  are  herded  together  in  tene- 
ments, tuberculosis  is  very  prevalent.    Generally  speaking  the  poor 


TUBERCULOSIS  461 

are  more  subject  to  the  disease  than  the  rich  on  account  of  the  poor 
nutrition  and  imperfect  sanitation  of  the  former. 

Occupations  which  compel  inactive,  indoor  living,  especially 
in  bad  air,  are  those  in  which  tuberculosis  occurs  most  frequently. 
Tailors,  for  example,  sitting-  in  cramped  positions,  in  badly  ven- 
tilated, overheated  rooms,  with  the  lint  from  cloth  flying  in  the  air, 
are  especially  subject  to  the  disease. 

Pathology.  The  characteristic  pathology  of  tuberculosis  is  that  of 
the  tubercle,  a  semitransparent  gray  gelatinous  body,-  just  visible  to  the  naked 
eye,  which  later  becomes  opaque,  and  softens  in  the  center.  They  are  produced 
by  the  local  specific  irritant  action  of  the  bacilli  and  may  be  few  or  numerous 
in  the  affected  organs. 

The  growth  of  the  bacilli  in  the  tissues  excites  a  proliferation  of  the 
neighboring  cells.  Certain  of  these  cells  which  are  situated  in  the  center,  as  a 
result  of  an  increase  in  their  size  and  repeated  division  of  their  nucleus,  or  by 
fusion  of  contiguous  cells,  become  giant  cells.  Bacilli  are  found  in  these 
endothelial  and  giant  cells.  Around  this  cell  mass  is  a  zone  composed  of  small 
round  cells  surrounded  by  a  network  of  fibrous  tissue.  This  tubercle  being 
nonvascular  is  open  to  degenerative  changes  as  caseation  and  coagulation,  encap- 
sulation, or  calcification. 

The  bacteria  themselves  being  walled  in  by  the  connective  tissues  of  increas- 
ing density  ultimately  die.  The  dead  bacteria,  the  plasma  cells,  the  old  blood 
corpuscles  which  are  entangled  with  them  all  become  degenerated  into  a 
cheesy  mass.  If  no  secondary  infection  occurs  the  complete  death  of  the  bacilli 
and  the  increasing  thickness  of  the  connective  tissue  wall  around  the  tubercle 
terminates  the  process.  If,  however,  the  ordinary  pyogenic  bacteria  gain  entrance 
into  the  injured  tissues  or  into  the  tubercle  itself  pus  is  formed.  If  the  staphylo- 
coccus is  the  invading  agent  the  abscess  formation  is  rather  slow  and  chronic, 
and  the  health  of  the  patient  is  not  materially  affected  thereby.  If  the  strepto- 
coccus of  any  of  the  ordinary  varieties  should  be  the  more  important  invader 
the  abscess  formation  is  rapid,  the  amount  of  pus  plentiful,  and  the  patient's 
health  suffers  very  severely.  In  either  case  the  tubercle  becomes  broken  down 
into  soft  pus  and  the  condition  which  is  called  tubercular  abscess  is  present. 
Tubercles  may  grow  together  and  become  confluent,  thus  causing  a  consolida- 
tion of  very  large  areas  of  the  lung  tissue.  These  being  broken  down  result 
in  the  formation  of  abscesses  and  cavities  of  great  size.  The  description  of  the 
tubercle  as  given  for  the  lung  applies  with  almost  equal  verity  to  tubercle  in 
almost  any  part  of  the  body,  except  the  brain.  In  the  brain  the  tubercle  bacilli 
multiply  upon  the  pia  mater  or  upon  any  surface  of  the  brain  itself.  The  giant 
cells  do  not  appear  to  any  great  extent  in  this  locality  and  the  connective  tissue 
does  not  limit  the  growth  of  the  bacteria  to  any  one  region.  For  this  reason 
tuberculosis  affecting  the  brain  has  a  very  rapid  course,  very  severe  symptoms, 
and  usually  speedy  death. 

In  favorable  cases,  and  in  some  tubercles  even  in  fatal  cases,  the  wall  of 
the  tubercle  thickens,  the  pus  and  caseous  material  become  inspissated,  and  the 
bacteria  die;  the  whole  or  any  part  of  the  mass  may  become  calcified.  Recovery 
is  practically  complete  when  this  condition  is  universal.  Even  quite  large  pus 
cavities  may  become  healed,  and  filled  with  scar  tissue,  as  is  found  after  death 
from  later  tuberculosis  or  from  other  diseases.  A  partial  immunity  is  estab- 
lished by  recovery  from  tuberculosis;  this  is  easily  broken,  and  patients  who 
are  convalescent  are  very  susceptible  to  reinfection,  either  from  themselves 
or  from  other  persons. 

Diagnosis.  Tuberculosis  should  be  suspected  when  any  patient 
loses  weight  gradually  with  no  recognizable  cause.  An  early 
finding  is  mild  secondary'  anemia,  with  relative  lymphocytosis  and 


462  DISEASES  DUE  TO  BACILLI 

diminished  eosinophiles.  This  blood  picture  is  almost  pathogno- 
monic. The  X-ray  shows  very  early  changes  in  lungs  or  bones,  and 
is  helpful  in  any  case. 

Varying  rales  and  other  pulmonary .  sounds  depend  upon  the 
size  and  location  of  the  pulmonary  lesions.  The  subnormal  morn- 
ing temperature  with  afternoon  fever,  not  usually  above  101°  in 
the  early  stages,  is  usually  associated  with  pyogenic  infection. 
Night  sweats  are  also  indicative  of  pyogenic  infection.  (These 
may  sometimes  be  referred  to  a  habit  of  being  too  warmly  clothed 
at  night,  however.) 

The  sputum  varies  with  the  progress  and  the  type  of  the  dis- 
ease. Bacilli  of  tuberculosis  may  be  abundant,  or  may  be  found 
with  great  difficulty.  Inoculation  of  the  sputum  into  laboratory 
animals  may  give  the  diagnosis  in  doubtful  cases.  Small  white 
cheesy  masses  are  characteristic;  these  may  contain  the  bacilli  in 
large  numbers.  The  sputum  may  be  very  tenacious  and  heavy, 
or  may  be  thin  and  frothy.  It  may  contain  alveolar  cells,  blood, 
ciliated  cells,  and  various  micro-organisms  which  include  harmless 
as  well  as  virulent  forms. 

Other  diagnostic  points  are  mentioned  in  connection  with  the 
various  forms  of  the  disease. 

The  treatment  of  tuberculosis  should  be  based  upon  a  recogni- 
tion of  the  conditions  as  found  upon  the  examination  of  each  indi- 
vidual patient,  together  with  the  results  of  the  investigations 
made  into  the  pathology  and  the  progress  of  the  disease  by  various 
investigators. 

The  correction  of  whatever  factors  are  found  which  have  been 
instrumental  in  causing  the  disease,  in  each  individual,  and  which 
are  efficient  in  perpetuating  the  disease,  must  be  removed  as 
speedily  as  possible  under  the  circumstances  in  each  case.  It  must 
be  urgently  insisted  upon  that  each  patient  is  to  some  extent  a 
law  for  himself,  and  the  most  speedy  and  complete  recovery  is 
secured  only  when  the  entire  individuality  of  each  patient,  his 
history  and  his  environment,  his  tastes  and  his  mental  habits,  are 
taken  into  consideration. 

The  corrective  work  includes  usually  two  factors:  first,  the 
lesions  which  lower  the  body  resistance  to  tubercular  invasion, 
and  second,  the  lesions  which  permit  the  invasion  of  the  particular 
tissues  affected. 

The  correction  of  these  lesions  is  easy  in  the  earlier  stages 
of  the  disease,  but  after  the  formation  of  cavities  and  abscesses 
is  suspected,  considerable  care  is  necessary,  in  order  to  prevent 
the  danger  of  injuring  the  walls  of  ,these  formations,  as  well  as 
of  precipitating  hemorrhages. 

"What  I  would  emphasize  above  all  else  is  the  necessity  of  administering 
corrective  treatment  with  a  full  understanding  of  the  pathological  condition 
present,  and  the  fact  that  the  strictly  osteopathic  lesion  present — and  to  be  cor- 


TUBERCULOSIS  463 

rected  above  all  else — is  a  posterior  upper  lumbar  and  an  anterior  lower  dorsal. 
With  care  and  certainty  in  the  correction  of  this  lesion,  with  palliative  treat- 
ment as  indicated,  and  with  attention  to  any  other  osseous  lesion  that  may 
be  present,  the  correction  of  which  is  not  contra-indicated  by  the  pathological 
lesion  in  the  lung,  you  may  be  assured  of  an  ultimate  result  not  surpassed  or 
even  approached  by  any  other  system  of  therapeutics  devised  by  the  brain  of 
man." — W.  B.  Meacham. 

."In  the  main  I  believe  it  is  better  for  the  natural  desires  of  the  patient  to 
determine  the  kind  and  quantity  of  food  taken.  I  do  not  believe  in  the  forced 
feeding  of  these  patients.  In  many  cases  where  the  stomach  is  not  disturbed 
at  all  the  ordinary  diet  can  be  maintained.  I  believe  one  great  essential  in  the 
treatment  of  tuberculosis  is  rest  of  the  patient,  both  body  and  mind.  *  *  *  As 
said  at  the  beginning,  the  real  cause  of  the  lowered  resistance  is  the  structural 
derangement  of  the  spine  and  chest,  and  observation  and  many  observers  main- 
tain that  these  lesions  are  located  usually  at  the  second,  third,  and  fourth  ribs, 
over  the  diseased  lung.  Lesions  of  the  second  and  third  dorsal  should  also  be 
corrected.  Treatment  should  be  directed  to  the  cervical  region,  which  involves 
the  lymphatics  to  the  lung  and  to  the  vaso-motor  area  which  supplies  the  lungs 
with  blood  and  in  turn  increases  the  phagocytic  activity  of  the  leucocytes,  which 
are  the  chief  warriors  against  the  invading  germ.  The  clavicles  should  be  raised, 
as  also  any  ribs  that  are  drawn  down." — C.  A.  Williams. 

Open  air  living-  is  urgently  desirable.  In  mild  climates,  day 
and  night  should  be  spent  out  of  doors.  In  inclement  weather, 
protection  is  necessary ;  there  are  many  appliances  which  permit 
out-door  air  to  reach  the  nose  and  mouth,  while  the  rest  of  the 
body  is  kept  in  the  warm  room.  It  is  most  important  that  the 
patient  be  kept  warm,  dry  and  comfortable.  Hot  water  bags  atfd 
warm  coverings  are  essential.  Too  great  warmth  .upon  retiring 
leads  to  more  severe  night  sweats;  these  can  often  be  avoided  by 
having  the  bed  warm  upon  retiring,  but  with  rather  less  than  the 
usual  coverings.  Indeed,  many  night  sweats  are  due  to  nothing 
more  than  an  excess  of  bed  coverings. 

The  change  of  climate  so  often  recommended  is  of  chief  value 
in  the  early  stages  of  the  disease,  and  must  be  advised  only  after 
a  consideration  of  all  factors  concerned.  A  sudden  change  to  a 
warm  climate  may  be  enervating;  homesickness  may  be  a  serious 
matter;  comforts  of  home  may  be  lacking;  the  money  spent  in 
the  change  may  necessitate  lack  of  proper  food;  and  in  the  last 
stages  of  the  disease  it  is  rare  that  leaving  home  at  all  is  per- 
missible. On  the  other  hand,  when  the  home  conditions  are  not 
good;  when  nervous  depression  is  a  factor;  when  the  patient  lives 
where  the  climatic  and  sanitary  conditions  are  bad;  when  he  is 
sensible  and  willing  to  make  an  endeavor  to  recover  his  health ; 
when  he  has  money  enough  to  live  on  without  worry,  a  change  of 
climate  is  stimulating  and  .refreshing,  and  if  this  is  associated  with 
out-door  life,  complete  change  of  scene,  good  food  and  proper 
structural  corrections,  recovery  may  occur  in  cases  which  appear 
almost  hopeless  at  first.  A  sanitarium  should  be  investigated 
before  a  patient  is  sent;  there  are  many  such  places  where  every 
condition  makes  for  the  most  speedy  recovery ;  there  are  others 
where  the  sanitary  conditions,  crowding,  and  diet  are  absolutely 


464  DISEASES  DUE  TO  BACILLI 

destructive.  Happiness  is  important  in  these  cases;  fortunately- 
tubercular  patients  are  usually  hopeful.  Altitude  is  less  important 
than  other  factors;  the  high  altitude  is  usually  advised;  3,000  to 
6,000  feet  is  a  very  good  height  in  good  climates.  Dryness  is  more 
constant  at  the  high  altitudes;  cough  is  often  relieved  more  by  a 
lower  altitude.  If  a  patient  does  not  get  along  well  in  the  moun- 
tains, a  lower  place,  usually  not  very  near  the  sea,  should  be  tried. 

Diet  is  of  importance,  though  perhaps  of  less  moment  than  has 
been  supposed.  "Stuffing"  is  obsolete;  increased  swallowing  does 
not  necessarily  mean  increased  nutrition.  Tubercular  patients  need 
greater  amounts  of  proteids,  fats,  and  the  vegetable  salts  than  do 
normal  people;  this  is  because  poor  nutrition  is  an  important 
factor  in  causing  the  disease,  "a  functional  lesion,"  if  the  term  be 
permissible.  "Calory  feeding"  is  a  method  used  in  some  sani- 
tariums; the  patient  is  given  a  menu  at  each  meal,  in  which  the 
calory  value  of  each  article  of  diet  is  given.  He  must  choose  from 
this  menu  whatever  kind  of  food  he  likes,  but  the  sum  of  calories 
must  equal  the  amount  prescribed  for  him  on  examination  each 
week.  Intelligent  patients  may  be  taught  to  estimate  calory 
values,  and  to  diet  themselves  at  home. 

Many  patients  have  ideas  of  what  they  can  and  cannot  eat ; 
these  ideas  may  have  been  a  cause  of  the  original  malnutrition, 
and  they  must  be  taught  to  overcome  foolish  prejudices.  It  is 
rarely  advisable  to  force  food  down  a  rebellious  gullet.  Either  the 
patient  must  be  talked  into  a  more  rational  viewpoint  concerning 
food  values,  or  the  essential  elements  must  be  given  him  in  some 
other  way — possibly  in  unrecognized  combinations.  Foods  which 
have  been  refused  may  contain  elements  necessary  to  nutrition ;  in 
such  cases  every  effort  must  be  made  to  replace  these,  or  similar 
substances,  in  the  diet  list. 

The  diet  must  include  fats,  such  as  cream,  butter,  olive  oil, 
bacon,  especially.  These  are  interchangeable ;  if  any  one  is  taken 
plentifully,  others,  which  may  not  be  appetizing,  may  be  omitted. 

Proteids  are  essential;  eggs,  milk  and  milk  products;  meat, 
especially  beefsteak,  chicken,  and  others ;  wild  meats  are  appetiz- 
ing, but  probably  not  more  nutritious ;  leguminous  foods  are  nutri- 
tious, but  cannot  substitute  for  other  proteids.  The  hemoglobin 
and  myohematin  of  meat  are  important  in  building  red  blood 
cells,  thus  providing  the  necessary  oxygen  supply  to  the  tissues. 

Chlorophyll  and  the  organic  compounds  of  inorganic  salts, 
found  in  vegetables,  are  valuable  aids  in  tissue  building.  Some  of 
these  are  broken  down  by  cooking;  so  that  some  raw  green  vege- 
tables should  be  eaten;  if  this  is  not  possible,  the  juices  pressed 
from  the  raw  green  vegetables  may  be  added  to  broths  until 
the  digestion  improves.    Cooked  vegetables  may  be  eaten,  but  the* 


TUBERCULOSIS  465 

raw  salads  must  not  be  omitted.  Raw  fruits,  especially  apples, 
are  to  be  freely  given. 

The  carbohydrates  are  usually  eaten  in  sufficient  quantities 
without  special  encouragement.  White  bread  may  be  eaten  if  it  is 
preferred  and  if  it  agrees  with  the  patient's  digestion.  The  dark 
breads  are  better.  Too  great  a  proportion  of  starches  and  sugars 
are'  to  be  avoided,  but  as  long  as  the  fats,  proteids  and  vegetables 
are  eaten  in  sufficient  quantity,  the  carbohydrate  question  may 
usually  be  left  to  the  appetite  of  the  patient. 

It  is  often  useful  to  add  to  the  number  of  meals  eaten ;  a  lunch 
of  milk,  fruit,  broth,  or  some  one  such  thing  may  be  given  at  two 
or  three  hour  intervals.  A  cup  of  hot  milk  or  broth  before  arising 
and  before  retiring  are  good ;  each  patient  is  a  law  to  himself  in 
regard  to  details;  the  important  thing  is  to  promote  nutrition. 
During  the  feverish  periods  solid  foods  are  best  omitted ;  fruits  or 
fruit  juices  or  buttermilk  may  be  taken,  preferably  cold.  Pure, 
fresh  ice  cream  may  be  eaten. 

Symptoms  must  be  treated  as  they  occur.  One  rule  is  absolute: 
the  patient  must  rest  during  the  feverish  periods.  A  temperature 
above  100°  F.  should  send  the  patient  to  bed ;  he  cannot  be  on  his 
feet  until  the  temperature  goes  down  to  99°  F.  Exercise  in  the 
mornings,  or  in  the  absence  of  fever,  may  depend  upon  his  inclina- 
tion, usually. 

Hemorrhages  vary  greatly;  they  give  little  information  as  to 
the  prognosis  in  ani^  case.  Very  severe  hemorrhages  may  be  fatal, 
of  course.  Rest  is  important;  the  patient  should  remain  in  bed 
after  recognizable  loss  of  blood;  merely  stained  sputum  is  of  no 
importance.  Strong  inhibition  around  the  tenth  thoracic  spine 
lowers  blood  pressure,  and  lessens  hemorrhage.  Gelatine  feeding 
seems  to  increase  the  coagulability  of  the  blood,  thus  diminishing 
the  danger  of  hemorrhage. 

Cough  may  be  distressing,  and  may  prevent  sleep.  Thorough 
relaxation  of  the  cervical  and  interscapular  tissues  helps  in  relieving 
cough ;  inhibition  of  the  tenth  thoracic  region  is  useful  here  also. 
Sometimes  the  patient  can  stop  cough  by  bending  forward,  with 
the  muscles  relaxed  and  the  head  falling  forward ;  this  is  usually 
followed  by  easy  expectoration  of  increased  amounts  of  sputum. 

Emaciation-  may  cause  pain  upon  the  bones  subjected  to  pres- 
sure in  sitting  or  lying;  water  cushions  or  air  cushions  are  good 
in  such  cases. 

The  swelling  of  the  legs  may  usually  be  greatly  relieved  by  the 
leg  movements,  relaxing  the  tissues  around  Poupart's  ligament 
and  around  the  groin.  The  tissues  around  the  sciatic  nerve  should 
be  examined,  and  any  tension  relieved.  The  rotation  and  elevation 
of  the  legs,  with  every  possible  easy  bending  and  stretching,  give 
relief  which  persists  for  days,  sometimes. 


466  DISEASES  DUB  TO  BACILLI 

The  mental  depressions  sometimes  present  when  the  lower 
lobes  of  the  lungs  are  involved,  or  when  cardiac  or  gastric  compli- 
cations exist,  are  hard  to  handle.  More  frequent  feeding  helps; 
an  explanation  of  the  source  of  the  gloom — gastric,  especially — 
helps  the  patient  to  exercise  self-control.  Surroundings  are  rarely 
able  to  give  cheer;  but  every  effort  should  be  made  to  keep  him 
happy  as  is  possible.  Forebodings  may  be  hailed  as  evidence  of 
the  nonexistence  of  tuberculosis  in  some  cases  in  which  the  diag- 
nosis is  doubtful. 

Prognosis.  In  the  early  stages  the  prognosis  for  complete 
symptomatic  recovery  is  good.  Destroyed  tissue  is  replaced  by 
scar  tissue,  and  since  lungs  contain  several  times  as  much  area 
as  is  really  needful,  the  patient's  life  need  not  be  shortened  nor 
made  less  happy  and  efficient  by  his  experience.  After  recovery, 
the  weight  should  be  watched  for  about  five  years;  if  no  loss  of 
weight  nor  other  symptoms  appear,  recovery  may  be  considered 
complete.  He  is  not  immune  to  later  attacks,  and  should  remain 
in  the  region  of  his  improved  health,  and  should  keep  up  his 
rational  habits  of  living. 

In  the  later  forms  of  chronic  tuberculosis ;  in  the  miliary  types, 
and  in  cases  complicated  by  other  diseases,  the  prognosis  is  bad 
for  recovery,  but  good  for  relief  of  symptoms  and  improved  com- 
fort. 

Acute  Pulmonary  Tuberculosis  (Acute  phthisis ;  florid  phthisis ; 
catarrhal  phthisis;  caseous  pneumonia;  galloping  consumption). 
This  is  an  acute  type  of  pulmonary  tuberculosis  characterized 
anatomically  by  inflammation,  caseation,  and  liquefaction  of 
lung  substance,  and  clinically  by  hectic  fever,  coughs,  night 
sweats,  prostration,  dyspnea,  and  the  expectoration  of  large 
quantities  of  sputum  which  usually  contain  tubercle  bacilli  and 
pyogenic  organisms.  Two  types  are  recognized;  pneumonic  and 
broncho-pneumonic.  A  subacute  form  of  either  type  is  recognized, 
which  may  become  chronic. 

The  pneumonic  type  simulates  croupous  pneumonia,  but 
usually  affects  the  upper  lobes.  The  onset  is  sudden,  following  a 
chill  with  pain  in  the  side,  remittent  fever,  cough  with  a  profuse 
expectoration,  which  is  soon  rusty  and  purulent,  dyspnea,  night 
sweats  and  rapid  emaciation.  After  a  few  days  the  tubercle 
bacilli  and  elastic  fibers  are  found  in  the  sputum.  There  is  rapid 
loss  of  flesh  and  strength  arid  the  patient  succumbs  in  a  few  weeks. 
It  may  become  prolonged  and  last  for  months. 

Tubercular  bronchopneumonia  is  more  frequent  than  the  pre- 
ceding condition  and  usually  occurs  in  children  following  measles 
and  whooping  cough.    The  onset  is  gradual  with^ectic  fever,  rapid 


TUBERCULOSIS  467 

pulse  and  respiration,  severe  cough,  dyspnea,  night  sweats  with 
rapid  emaciation  and  prostration. 

Both  lungs  are  attacked,  especially  the  upper  lobes,  and  present 
branching  areas  of  caseation  with  small  ragged  cavities.  The 
thorax  shows  signs  of  a  diffuse  bronchitis  with  increased  vocal 
fremitus  and  apical  dullness  upon  percussion,  with  mucous  and  sub- 
crepitant  rales. 

Chronic  Pulmonary  Tuberculosis  (Tubercular  phthisis;  con- 
sumption ;  incipient  phthisis ;  chronic  phthisis  and  chronic  ulcer- 
ative phthisis).  A  chronic  pulmonary  disease  characterized 
anatomically  by  the  ulceration  and  softening  of  tubercles  situated 
in  the  lung  tissue  inducing  a  septic  infection  and  clinically  by  fever, 
cough,  dyspnea,  emaciation  and  exhaustion. 

Symptoms.  The  onset  is  insidious — is  usually  attended  with 
gastrointestinal  disturbances  as  anorexia,  dyspepsia,  epigastric 
distress  after  meals,  malaise,  pallor  and  secondary  anemia  and 
cough.  Soon  an  afternoon  temperature  is  noticeable  and  a  little 
later  night  sweats  appear;  face  is  flushed,  eyes  glassy,  pupils 
dilated,  cough  becomes  more  severe  with  free  expectoration,  pro- 
gressive emaciation  with  marked  loss  of  weight  and  impaired 
strength,  pains  in  the  chest,  dyspnea,  irritable  heart,  and  diarrhea 
which  may  alternate  with  constipation.  Although  the  emaciation 
and  weakness  become  profound  the  patient  is  hopeful  until  the 
end  (spes  phthisica).  The  cough,  which  is  one  of  the  first  and 
distressing  symptoms,  is  at  first  dry  and  hacking  with  little  expec- 
toration, but  later  with  consolidation  is  aggravated ;  the  expecto- 
ration is  mucopurulent  and  contains  the  bacilli  and  elastic  fibers. 
With  cavity  formation  the  cough  becomes  very  severe  and  pro- 
fuse; the  expectoration  is  purulent,  greenish  in  color  and  made 
up  of  heavy  coin-shaped  plugs  which  sink  when  placed  in  water 
(nummular  plugs). 

Pain  when  present  is  due  to  an  associated  inflammation  of  the 
pleura.  Often  respiration  is  increased  to  thirty  or  more  per 
minute.  Dyspnea  is  not  marked  except  in  the  later  stages  or 
upon  exertion.  Hemorrhages  may  be  early  or  late.  The  blood 
may  be  bright  red  and  frothy  or  dark  and  heavy  from  stagnation. 
Hemorrhages  are  caused  either  by  a  hyperemia,  or  more  frequently, 
from  an  erosion  of  the  blood  vessels  or  rupture  of  an  aneurysm. 

The  fever  is  quite  characteristic.  At  first  there  is  only  a  slight 
elevation  in  the  afternoon,  but  later  with  beginning  degeneration 
of  the  tubercular  areas  the  fever  presents  a  remittent  type.  With 
cavity  formation  it  is  always  intermittent,  the  highest  temperature 
occurring  in  the  afternoon  about  four  o'clock,  with  the  lowest  in  the 
correspondingly  early  morning  hours. 

Associated  with  a  decrease  in  temperature  is  the  sweating 
which  is  often  excessive,  saturating  the  bed  clothes  and  producing 


468  DISEASES  DUE  TO  BACILLI 

great  exhaustion.  Emaciation  always  occurs  in  the  later  stages 
of  the  disease  and  is  due  to  the  fever  and  impaired  digestive  and 
assimilative  powers.  The  thorax  and  extremities  are  more  com- 
monly affected.  With  cavity  formation  and  hectic  fever  there 
occurs  a  marked  leucocytosis  which  is  probably  caused  by  a  sec- 
ondary infection  by  one  of  the  pyogenic  organisms.  The  gastro- 
intestinal symptoms  are  anorexia,  constipation,  alternating  with 
diarrhea  and  gastric  catarrh.  The  genito-urinary  symptoms  are 
due  to  a  fever  and  toxemia  characterized  by  decreased  elimination 
and  dropsy.    Albumin  and  casts  are  found  in  the  urine. 

Inspection  usually  shows  a  long  and  narrow  emaciated  chest, 
ribs  depressed  and  oblique,  costal  arch  very  acute ;  cartilages  prom- 
inent, sternum  depressed,  scapulae  winged,  clavicles  prominent  with 
supra  and  infra  clavicular  areas  depressed.  The  interscapular 
region  is  immobile  and  flat.  The  X-ray  gives  much  more  accurate 
information  than  ordinary  methods  of  diagnosis.  The  first  areas 
involved  are  usually  under  the  sternum. 

In  the  early  stages  a  slight  dullness  is  found  over  the  apices, 
more  commonly  on  the  right.  Later  with  marked  consolidation 
and  expansion  of  the  parts  the  area  of  dullness  is  increased  and 
may  be  elicited  above  or  below  the  clavicles  or  between  the  scap- 
ulae. With  cavity  formation  a  tympanitic  or  cracked-pot  note  is 
detected.  In  the  early  stages  respiration  may  be  inaudible  over 
the  affected  area.  Later  the  breathing  is  harsh  and  expiration  is 
prolonged.  Crackling  rales  are  usually  detectable  and  if  not  pres- 
ent coughing  will  develop  them.    The  vocal  resonance  is  increased. 

Auscultation  over  cavities  may  detect  cavernous  or  amorphic 
breathing  with  large  bubbling  and  gurgling  rales.  Bronchophony 
and  pectoriloquy  may  be  present.  The  irregular  fever,  cough, 
pallor,  emaciation,  hemoptysis,  night  sweats,  signs  of  consolidation 
and  cavity  formation;  the  presence  of  bacilli  and  elastic  fibers  in 
the  sputum  are  all  characteristic,  and  these  confirm  the  diagnosis. 

Prognosis.  This  varies  with  the  stage  of  the  disease,  but  gen- 
.erally  it  is  very  unfavorable  as  the  individual  dies  of  exhaustion 
in  about  two  years.  Many  cases  under  the  influence  of  dry,  rari- 
fied  atmosphere,  rest,  sunshine,  good  food  with  fresh  green  vege- 
tables and  light  spinal  treatment  are  prolonged  indefinitely  and 
often  the  process  is  rendered  latent.  Unfavorable  signs  are  high 
temperature  and  rapid  pulse,  continued  gastric  and  intestinal  dis- 
turbances and  the  development  of  secondary  tubercular  processes. 

Acute  Miliary  Tuberculosis  (Acute  phthisis ;  galloping  con- 
sumption). This  is  an  acute  infectious  febrile  disease  character- 
ized anatomically  by  the  general  or  local  development  of  miliary 
tuberculosis,  and  clinically  by  the  symptoms  of  an  acute  infection ; 
this  may  be  generalized  (typhoid),  pulmonary,  or  cerebral,  accord- 
ing to  the  locality  chiefly  infected.  ♦ 


TUBERCULOSIS  469 

This  acute  form  of  tuberculosis  occufs  more  frecjuently  in 
infants  and  children  than  adults  and  with  few  exceptions  is  sec- 
ondary to  an  active  or  latent  tubercular  process  in  the  lymphatic 
nodes,  bones  or  lungs.  It  may  follow  other  infectious  diseases  as 
measles,  whooping  cough,  variola  or  influenza.  The  bacilli  are 
probably  disseminated  by  the  blood. 

General  or  Typhoid  Tuberculosis.  The  onset  is  gradual  with 
headache,  anorexia,  malaise,  progressive  weakness  and  moderately 
high,  irregular  temperature  (102°  or  104°  F.),  hurried  respiration, 
rapid  and  feeble  pulse.  Cough  and  sweating  may  or  may  not  be 
present.  As  the  disease  advances  typhoid  symptoms  develop  as 
brown  fissured  tongue,  mutteriilg  delirium,  subsultus  tendinum, 
carphologia,  but  soon  the  prostration  becomes  more  profound,  and 
cyanosis  develops  with  stupor  and  coma.  Death  supervenes  within 
six  to  eight  weeks. 

Acute  Pulmonary  Miliary  Tuberculosis.  In  this  form  the 
tubercles  are  chiefly  located  within  the  lung  tissue.  The  onset  is 
usually  sudden  with  a  chill  and  a  previous  history  of  cough  or 
chronic  phthisis  and  in  children  of  measles  or  whooping  cough. 
Respiration  is  rapid.  Dyspnea  and  cyanosis  are  marked.  Fever  is 
high,  102°  to  104°,  with  pain  in  the  chest  and  prostration.  Sputum 
is  abundant  and  may  be  rusty  in  color.  Elastic  fibers  and  tubercle 
bacilli  may  be  found.     Leucocytosis  may  be  marked. 

Progressive  emaciation  and  anemia  are  accompanied  by  vertigo, 
headache,  sleeplessness,  coma  and  death,,  which  occurs  in  from 
four  to  twelve  weeks. 

Tubercular  Meningitis  (Basilar  meningitis;  acute  hydroceph- 
alus) is  an  acute  tubercular  inflammation  of  the  pia  mater  charac- 
terized by  cerebral  irritation  and  compression,  emaciation  and 
death. 

This  usually  occurs  in  scrofulous  children,  between  two  and 
seven  years  of  age  and  is  almost  always  secondary  to  some  other 
tubercular  process  in  the  body.  The  tubercles  are  found  along  the 
blood  vessels  in  the  pia  mater,  usually  at  the  base  of  the  brain 
as  grayish-white,  transculent  gelatinous  granules  causing  a  produc- 
tive inflammation  with  consequent  thickening  and  opacity  of  the 
membranes.  The  resulting  inflammatory  exudate  confined  to  the 
cranial  cavity  and  the  accompanying  toxemia  produces  the  symp- 
toms. 

The  onset  is  insidious  with  irritability,  anorexia,  headache, 
sleeplessness,  constipation,  loss  of  flesh  and  irregular  periods  of 
fever.  This  lasts  from  a  week  to  a  month  and  gradually  passes 
into  the  stage  of  excitation. 

This  is  characterized  by  projectile  vomiting,  severe  headaches, 
convulsions  and  fever  ranging  from  98°  in  the  morning  to  103° 
or  104°  in  the  evening  with  an  irregular  compressible  pulse,  retrac- 


470  DISEASES  DUE  TO  BACILLI 

tion  of  the  head,  photophobia,  tinnitus  aurium,  vertigo,  contracted 
pupils,  muscular  twitching,  intolerance  to  sound  with  the  hydro- 
cephalic cry  and  cutaneous  hyperesthesia.  This  stage  lasts  from 
two  weeks  to  a  month  and  passes  into  the  stage  of  depression. 

In  this  stage  all  the  symptoms  of  cerebral  irritation  abate.  The 
vomiting  and  headache  gradually  subside.  Temperature  is  less, 
pupils  dilated,  pulse  slow,  irregular  and  compressible.  Respiration 
irregular  and  sighing,  periodic  convulsions,  strabismus,  carphol- 
ogia,  mental  stupor  and  paralysis  are  frequent.  Collapse  finally 
occurs  with  Cheyne-Stokes  breathing  and  coma  \^hich  terminates 
in  death  in  a  day  to  a  week. 

Fibroid  Phthisis  (Chronic  interstitial  pneumonia;  cirrhosis  of 
the  lungs;  Corrigan's  disease).  This  is  a  chronic  inflammatory, 
condition  of  the  lung,  characterized  anatomically  by  an  increase 
in  the  connective  tissue,  decrease  of  the  parenchymatous  structures 
and  clinically  by  emaciation,  cough  and  mucopurulent  expectora- 
tion containing  the  tubercle  bacilli. 

Pathology.  The  disease  is  caused  by  the  bacilli  of  tuberculosis,  but 
predisposing  is  a  low-grade  inflammatory  condition  of  the  supporting  structure 
of  the  lung  causing  a  fibrosis  of  the  interstitial  tissue  with  pressure  atrophy  of 
the  alveoli.  The  common  irritants  are  those  which  occur  in  the  pursuit  of  occu- 
pation, such  as  chemistry,  stone  cutting,  grinding,  mining.  The  straining  respira- 
tory excursion  causes  a  dilation  of  the  bronchi  and  bronchiectasis  results.  The 
process  usually  begins  in  one  apex  and  gradually  extends  over  the  whole  lung, 
seldom  affecting  both  sides.  The  lung  is  hard  and  fibrous ;  the  alveoli  oblit- 
erated. It  resists  cutting  and  upon  section  presents  a  dry  gray,  marble  appear- 
ance and  areas  of  caseation.  The  unaffected  areas  are  emphysematous  and  the 
right  ventricle  of  the  heart  is  always  hypertrophied."  From  the  long-continued 
toxemia  amyloid  degeneration  is  found  in  the  abdominal  organs. 

Diagnosis.  The  onset  is  very  gradual,  characterized  by  a  per- 
sistent cough  occurring  in  paroxysms  in  the  morning  with  a  pro- 
fuse mucopurulent  expectoration  containing  the  bacilli.  If 
bronchiectasis  is  present  it  may  be  fetid.  This  condition  may 
last  for  years  with  only  slight  loss  of  weight  but  later  irregular 
fever  with  night  sweats  and  dyspnea  develop.  Edema  due  to 
failure  of  the  circulation  is  accompanied  by  rapid  emaciation  and 
eventually  death.  The  course  of  the  disease  is  from  five  to  twenty 
years. 

X-ray  plates  indicate  the  location  and  extent  of  the  lesions. 

Inspection  shows  a  retraction  over  the  affected  area  due  to 
contraction  of  the  mature  connective  tissue.  Palpation  shows  les- 
sened respiratory  excursion  with  increased  vocal  fremitus.  Per- 
cussion shows  a  dullness  and  impaired  resonance  over  the  aflfected 
region  with  temporary  or  impaired  resonance  of  the  adjoining 
emphysematous  areas.  Auscultation  in  the  early  stages  shows 
vesicular  breathing  with  large  and  small  moist  rales,  but  later  the 
breathing  is  bronchial,  broncho  cavernous  or  cavernous  with  local- 
ized gurgling  rales. 


TUBERCULOSIS .  471 

Scrofula  is  a  mild  tubercular  inflammation  of  the  lymphatic 
nodes.  It  occurs  in  children  and  young  adults  with  a  weak- 
ened constitution  which  is  probably  hereditary.  Cervical  and 
upper  dorsal  lesions  so  alter  the  circulation  to  the  head  and  neck 
structures  that  the  resistance  of  the  lymphatic  nodes  is  lowered 
and  when  the  tubercle  bacilli  enter  the  lymph  stream  through 
diseased  tonsils  or  nasopharyngeal  membranes  they  are  able  to  pro- 
liferate and  produce  their  characteristic  reaction.  'It  occurs  more 
often  in  the  colored  than  the  white  race  and  usually  affects  the 
cervical  region,  but  is  occasionally  found  in  the  bronchial  and 
mesenteric  nodes.    Rarely  it  affects  all  the  nodes  of  the  body. 

It  is  first  noticed  as  slight  kernels  under  the  angle  of  the  jaw 
which  slowly  enlarge  until  the  whole  chain  causes  a  marked  swell- 
ing in  the  anterior  cervical  triangle. 

The  nodes  are  tender  upon  manipulation,  are  solid  and  move 
under  the  skin.  Accompanying  symptoms  are  moderate  fever, 
headache,  restlessness,  anorexia  and  constipation.  Later  as  sup- 
puration occurs  the  nodes  soften  and  become  adherent  to  the  over- 
lying tissue;  these  are  perforated,  allowing  a  dark  colored  dis- 
charge to  escape.  The  symptoms  are  always  exaggerated  during 
suppuration,  but  abate  as  the  toxemia  is  relieved  and  the  process 
tends  to  take  a  chronic  course  which  may  last  for  months  or  years. 

The  bronchial  lymphatics  are  often  affected ;  they  become  hard- 
ened and  calcified,  and  are  easily  recognized  by  the  X-ray  during 
life.  These  may  cause  later  irritative  symptoms,  and  may  lead  to 
an  unbased  diagnosis  of  fibroid  phthisis. 

M.  L.  Burns  reports  calcified  tubercular  bronchial  lymphatic 
nodes  found  by  X-ray  examination  in  patients  with  local  pain  and 
persistent  cough,  but  no  other  tubercular  symptoms. 

In  such  cases  correcting  the  cervical  lesions  and  raising  the 
ribs  and  sternum,  with  the  establishment  of  better  habits  of  breath- 
ing is  usually  followed  by  relief  of  the  symptoms. 

Tuberculous  laryngitis  (Laryngeal  phthisis;  throat  consump- 
tion) is  an  infection  of  the  larynx  with  the  bacillus  tuberculosis. 
It  is  characterized  by  ulceration,  dysphagia,  cough,  weakness  of 
voice,  hectic  fever,  and  progressive  emaciatiori.  It  is  nearly  always 
secondary  to  pulmonary  tuberculosis. 

Huskiness  proceeds  to  a  painful  whisper.  General  ill-health; 
irritable,  short,  frequent,  husky,  ineffectual  cough ;  frequently 
severe  pain,  increased  by  swallowing;  local  dryness  and  rarely 
paresthesias  are  noted.  Dsypnea  is  marked  and  edema  is  present. 
There  is  sometimes  suffocation  on  swallowing.  Irregular  fever, 
night  sweats,  and  other  symptoms  of  pulmonary  tuberculosis  are 
usually  present. 

Examination  of  the  larynx  very  early  shows  local  anemia.  A 
little  later,  there  are  numerous  bilateral,  pale,  round,  or  pointed 


472  DISEASES  DUE  TO  BACILLI 

eminences.  These  become  broad,  shallow,  irregular,  ill-defined, 
slow,  painful  ulcers  with  gray  bases  and  raised  edges.  The  vocal 
cords  and  epiglottis  are  infiltrated,  thickened,  and  paralytic,  often 
being  destroyed  late  in  the  course  of  the  disease.  There  is  local 
soreness  on  pressure  and  often  enlarged  cervical  lymphatic  glands. 
The  sputum  is  moderately  gray,  thick,  ropy,  and  mucoid  con- 
taining the  bacillus  of  tuberculosis. 

Treatment  includes  that  of  tuberculosis  in  general,  with  local 
treatment  to  render  the  patient  comfortable.  The  larynx  should 
not  be  manipulated  either  internally  or  externally.  Relaxation 
of  the  cervical  and  upper  thoracic  tissues  is  usually  required.  The 
use  of  the  voice  is  forbidden,  the  patient  may  whisper  a  few 
words  at  a  time. 

Tuberculous  Peritonitis  is  usually  secondary  to  infection  of  the 
intestine,  whether  intact  or  ulcerated.  In  women,  it  may  originate 
in  the  Fallopian  tubes.    In  males  it  may  follow  testicular  disease. 

It  may  complicate  phthisis.  It  is  most  common  in  children, 
again  between  the  ages  of  20  and  40,  and  may  occur  at  any  age. 

The  symptoms  may  set  in  acutely  with  considerable  fever, 
meteorism,  and  abdominal  pain,  or  the  onset  may  resemble  typhoid 
fever. 

In  children,  it  is  most  commonly  chronic  from  the  start,  with 
fever,  gradual  enlargement  of  the  abdomen,  areas  of  dullness  and 
resistance,  and  others  of  resonant  percussion.  Sometmies  dis- 
tinctly palpable  nodules  due  to  enlarged  glands  may  be  palpated ; 
at  other  times,  the  sausage-shaped  omental  tumor  is  found. 

The  general  symptoms  include  irregular  fever;  wasted  limbs 
and  thorax ;  persistent  diarrhea  which  often  alternates  with  consti- 
pation ;  the  stools  are  thin  and  offensive,  and  if  the  large  intestine 
is  involved,  streaked  with  mucus  and  blood.  There  are  moderate 
colicky  pains  and  tenderness;  profuse  sweating;  and  the  pleura  is 
sometimes  involved. 

The  local  symptoms  may  be  any  of  the  following:  Abdominal 
enlargement  with  effusion;  enlargement  with  tumor;  a  combina- 
tion of  both  of  the  above,  or  enlargement  without  evidence  of 
fluid  or  tumor. 

There  is  a  moderate  reduction  of  the  red  cells  in  some  cases; 
leucocytosis  is  not  constant.  The  eosinophiles  are  low  in  uncom- 
plicated cases. 

The  diagnosis  is  difficult  in  adults  but  is  assisted  by  evidence 
of  tuberculosis  elsewhere  in  the  body.  If  it  is  localized  in  the 
cecum  or  appendix,  a  tumorous  mass  may  develop.  The  tuberculin 
tests  may  be  of  use  in  the  diagnosis.  Most  of  these  have  an  ele- 
ment of  danger. 


TUBERCULOSIS  -      473 

Treatment.  Special  attention  should  be  given  the  lumbar  and 
dorsal  spinal  regions,  that  there  is  no  undue  muscular  contraction, 
and  that  there  are  no  spinal  or  rib  mal-adjustments. 

Rest  in  bed  is  advised,  with  plenty  of  fresh  air,  and  an  appro- 
priate diet  of  a  highly  nutritious  nature  and  rich' in  fats.  If  there 
is  much  diarrhea,  milk  alone  is  indicated.  The  abdomen  must  be 
kept  warmjiy  a  flannel  binder.  If  the  case  is  obstinate,  laparotomy 
with  evacuation  of  the  fluid  is  sometimes  followed  by  a  cure.  Ex- 
posure of  the  peritoneum  to  air  and  light  even  for  a  short  time 
seems  beneficial. 

Prognosis.  This  is  usually  unfavorable.  Long  and  tedious 
convalescence,  with  recurrences  of  the  symptoms  are  usual  in 
cases  which  recover. 

Tuberculous  Joints.  The  joints  are  affected  by  blood-borne  bac- 
teria. .  Probably  there  is  usually  some  traumatic  localizing  factor. 
The  tubercles  set  up  a  chronic  inflammation  in  the  synovial  mem- 
brane, or  they  may  affect  the  bones  themselves,  and  thence  invade 
the  joints. 

Pott's  disease  is  tuberculosis  of  the  spinal  column.  The  disease 
affects  the  bodies  of  the  vertebrae,  thus  removing  the  spinal  support. 
The  transverse  and  laminar  parts  of  the  vertebrae  are  thus  allowed 
to  fall  together,  whence  the  deformity. 

Hip  disease  is  tuberculosis  of  the  hip  joint. 

"A  tuberculous  joint  should  be  given  absolute  rest.  That  does  not  mean  that 
you  must  not  treat  the  patient  osteopathically.  The  patient  wants  osteopathic 
treatment  all  the  time,  and  it  does  not  mean  that  you  must  not  treat  the  joint 
osteopathically,  but  it  does  mean  that  you  must  not  manipulate  the  joint.  I  do 
not  mean  that  the  tissues  about  the  joint  cannot  be  very  carefully  manipulated, 
if  the  joint  is  not  disturbed;  but  I  do  mean  that  it  is  oftentimes  injurious  and 
mischievous  to  manipulate  any  articulation  of  the  body  where  there  is  chronic 
inflammation  ,due  to  any  infectious  agent,  tuberculous  or  otherwise.  There  is 
the  dividing  line  between  where  we  should  manipulate  an  inflamed  joint  and 
where  we  should  not.  Inflamed  joints  not  due  to  infection  in  the  joint  may 
be  manipulated  locally  and  much  benefit  result.  Where  we  have  an  inflamed 
joint,  an  acute  inflammation  due  to  an  infectious  process  (as  in  a  post  infectious 
arthritis  following  pneumonia),  or,  in  a  chronic  inflammatory  process  as  in 
tuberculosis  of  the  joint,  and  that  is  nearly  always  chronic,  leave  that  joint  alone; 
give  it  rest.  Improve  the  nutrition  to  the  joint  and  the  general  nutrition  of  the 
patient  all  you  can  by  giving  him  fresh  air,  sunshine,  pleasant  surroundings, 
good  food  and  plenty  of  it,  and  manipulation  of  the  spine  and  abdomen.  That 
is  the  kind  of  treatment  indicated,  but  have  the  joint  itself  absolutely  quiet.  Fix 
the  limb  in  such  position  that  the  patient  will  rest  and  ,by  so  doing  you  will 
prevent  deformity  and  get  quiescence  in  most  cases  after  several  months.  When 
the  symptoms  of  inflammation  in  the  joint  subside,  gentle  manipulation  should 
be  instituted  to  prevent  ankylosis." — Geo.  M.  Laughlin. 

"We  do  not  attempt  to  prevent  ankylosis  in  cases  of  tuberculosis  of  the 
hip.  Where  the  case  is  taken  early  we  can  often  restore  the  joint  to  good 
function,  but  in  well-developed  cases  ankylosis  in  good  position  is  desirable. 
Practically  in  Pott's  disease  ankylosis  in  good  position  gives  good  results." 
— Geo.  M.  Laughlin. 


474  DISEASES  DUB  TO  BACILII 

"In  all  tubercular  troubles  you  have  a  lowered  vitality.  If  you  confine  your 
treatment  to  the  local  conditions  and  neglect  the  general  conditions,  and  the 
matter  of  nutrition,  I  believe  you  will  make  a  failure. 

"I  would  give  them  as  nutritious  diet  as  possible,  and  besides  that  I  would 
feed  them  liberally  with  eggs,  milk  and  cream,  provided  the  digestive  organs  will 
stand  it,  or  some  foVm  of  assimilable  fats. 

"Then  you  have  the  condition  of  the  emunctories  to  look  after.  You  have 
the  condition  of  the  liver  and  the  spleen,  owing  to  the  mal-assimilation  which  is 
present  in  this  case.  You  will  have  to  look  to  the  splanchnics,  and  so  even  in 
the  absence  of  the  lesions  in  that  part  of  the  spine  throughout  the  splanchnics, 
I  would  thoroughly  relax,  and  I  would  thoroughly  spring  that  spine,  giving  as 
nearly  free  play  of  nerve  force  to  the  affected  part  as  I  could  possibly  do.  That 
is  about  all  the  corrective  work  that  is  necessary.  In  different  cases  you  must 
use  your  own  judgment." — P.  H.  Woodall. 

Tuberculosis  of  the  pericardium  is  rarely  recognized  ante- 
mortem.  It  is  practically  always  with  effusion,  and  the  aspirated 
liquid  is  blood  stained.  It  is  difficult  to  find  the  bacilli  in  th<i 
liquid,  but  inoculation  of  animals  gives,  usually,  positive  results. 
When  the  condition  is  recognizable,  death  is  probably  immment. 
This  is  sometimes  the  cause  of  death,  when  patients  apparently  in 
an  early  stage  of  pulmonary  tuberculosis  die  suddenly. 

Tuberculosis  of  the  kidneys  is  not  a  very  common  condition. 
The  diagnosis  is  suspected  when  hematuria  appears  in  a  tubercular 
individual.  Symptoms  of  nephritis  may  appear,  and  urinalysis 
show  pus,  renal  epithelium,  and  bacilli.  It  is  necessary  to  take 
great  care  to  avoid  confusing  smegma  bacilli  with  tubercular 
bacilli.  Accidental  contamination  of  the  urine  with  hay  bacilli  is 
also  to  be  avoided. 

Since  the  kidney  is  only  rarely  affected  primarily,  if  ever,  the 
lungs  should  be  examined  (best  by  the  X-ray)  for  tubercular  foci. 
X-ray  of  the  kidneys,  with  or  without  injection  of  contrast  solu- 
tions, may  give  the  diagnosis. 

For  milder  grades  and  with  marked  infection  of  other  organs, 
the  systemic  treatment  of  tuberculosis  is  all  that  should  be  done. 
When  one  kidney  is  seriously  involved,  while  the  other  kidney 
and  the  rest  of  the  body  are  reasonably  free  from  the  disease,  sur- 
gical treatment  may  be  considered. 

Tuberculosis  of  the  genital  organs  and  the  bladder  sometimes 
occurs.  Primary  disease  of  the  genitals  has  been  reported  but  is 
rare.  The  treatment  is  systemic  as  well  as  local.  Surgery  may  be 
indicated. 


CHAPTER  XUII 
LEPROSY 

Leprosy  is  a  chronic  specific  disease  caused  by  the  bacillus 
leprae,  and  characterized  by  the  development  of  cutaneous  tuber- 
cles, anesthetic  patches  or  neuritis,  and  followed  by  ulceration  and 
destruction  of  tissue.    These  forms  may  coexist  in  the  same  person. 

Etiology.  The  exciting-  cause  is  the  bacillus  leprae.  The  pre- 
disposing causes  are  use  of  common  drinking  vessels,  and  intimate 
contact.  The  modes  of  infection  are  probably  through  inoculation, 
minute  lacerations  as  scratch  marks,  use  of  a  common  pipe  or 
drinking  vessels.  The  contagion  is  from  open  sores,  saliva  and 
nasal  secretions,  and  through  infected  clothing-.  Several  types 
are  recognized. 

Tubercular  or  nodular  form.  With  or  without  prodromata,  red- 
dish or  bronzed,  erythematous,  slightly  elevated  patches  at  first 
hyperesthetic,  later  anesthetic,  appear  upon  the  face,  arms,  and 
knees.  They  fade  with  the  fever,  and  leave  brownish  stains  or 
slight  hardening.  After  weeks  or  months,  the  attack  is  repeated, 
perhaps  affecting  other  areas.  These  "leprous  storms"  keep  recur- 
ring and  ultimately  raised,  somewhat  tender,  nodules  appear  on 
the  site  of  the  former  eruption.  These  are  pink  at  first,  later 
becoming  a  dirty  brown  tint.  These  may  fade,  or  may  persist 
until  a  fresh  febrile  attack  adds  to  their  number.  The  skin  of  the 
face  is  thickened,  the  folds  deepened,  the  whole  face  is  broadened, 
and  assumes  a  "leonine"  aspect.  Nodules  appear  upon  the  limbs, 
the  cornea  is  attacked,  nasal  cavities  suffer  early  and  severely, 
fauces,  vocal  cords,  and  larynx  may  be  involved.  Blindness 
from  the  keratitis,  ozena,  aphonia,  cough,  hoarseness,  and  dyspnea 
occur.  The  nodules  ultimately  ulcerate,  open  sores  and  cica- 
trices being  seen  upon  the  skin.  The  constitution  suffers  from  the 
febrile  attacks,  weakness  first  and  then  prostration;  the  disease 
frequently  ending  in  phthisis.  The  duration  is  from  two  to  eigh£ 
years. 

Anesthetic  leprosy.  Prodromata  of  neuralgic  pains,  sometimes 
weakness,  and  wasting  of  the  fore  arm  muscles  may  last  for 
many  months.  Then  pale  or  light  yellowish,  itchy,  level  spots, 
often  symmetrical,  appear  upon  the  back  and  extensor  aspects  of 
the  limbs,  sometimes  upon  the  face,  while  the  corresponding  nerve 
trunks  are  thickened,  nodular,  and  tender.  This  stage  lasts  from 
two   to   three   years.     The   patches   become   anesthetic,   cease   to 

475 


476  DISEASES  DUE  TO  BACILLI 

secrete  sweat,  their  surface  is  white  and  their  edges  are  serpig- 
inous. Bullae  appear  on  the  limbs  and  trunk;  the  fingers  are 
contracted ;  the  phalanges  may  be  amputated  by  necrosis ;  perfora- 
ting ulcers  attack  the  feet  with  spontaneous  amputation  of  the 
toes;  the  ears  may  also  be  mutilated.  The  temperature  is  sub- 
normal except  during  the  eruption  of  bullae.  This  stage  lasts  from 
six  to  ten  years.  The  third  stage  is  marked  by  muscular  paralysis, 
the  third  and  seventh  nerve  being  often  affected,  and  by  dry  or 
moist  gangrene  of  the  extremities.  The  course  is  very  slow,  the 
patient  surviving  for  twenty  or  thirty  years. 

"Locally  (in 'Hawaii)  leprosy  is  not  considered  a  fatal  disease,  for  most  of 
the  patients  die  of  something  else.  *  *  ♦  Just  how  the  disease  is  transmitted  is 
not  known,  but  it  is  assumed  to  be  by  contact. 

"Symptoms — Usually  the  first  symptoms  to  appear  are  anesthetic  nodules  in 
the  skin  of  the  face,  arms,  or  legs.  The  smaller  ones  give  the  sensation  of 
imbedded  shot  on  passing  the  finger  over  the  skin.  They  attain  also  a  pea-size. 
These  nodules  are  filled  with  bacilli  leprae,  and  their  presence,  when  anesthetic, 
is  almost  diagnostic.  This  is  confirmed  by  incising  them,  making  a  scraping 
for  a  slide,  staining,  and  finding  bacilli  leprae  under  the  microscope.  The 
bacillus  of  leprosj'  is  rod  or  club  shaped,  similar  to,  but  thicker  than,  that  of 
tuberculosis;  it  occurs  often  in  chains,  but  more  often  sparsely;  yet  it  has  no 
absolutely  regular  shape,  no  constant  quality  except  sluggishness,  no  con- 
stant characteristic  except  that  of  being  'acid  fast,'  and  it  cannot  be  cultivated 
in  artificial  media  nor  in  animals.  In  these  facts  lies  the  chief  difficulty  of 
the  leper  situation. 

"The  bacillus  has  a  penchant  for  soft  pendulous  areas,  the  lobes  of  the  ears 
and  the  alae  nasi  of  lepers  being  usually  thickened  with  them  and  they  are 
always  present  in  the  nasal  discharges.  A  common  symptom  is  leucodermic 
areas,  whitish  patches  of  skin  anywhere  on  the  body  which  become  anesthetic; 
loss  of  sensation  occurs  in  any  region  invaded  by  the  bacilli. 

"Fingers  and  toes  become  enlarged,  and  distorted  by  flexion ;  extremities 
ulcerate  and  slough  away  by  erosion.  Of  all  the  strange  symptoms  of  this  slug- 
gish disease,  perhaps  the  ulcer  is  the  most  curious.  It  presents  a  clean,  raw 
surface  of  flesh,  yet  steadily  erodes  the  tissues  until  amputated.  A  foot  may 
become  hollowed  out  by  this  process  from  below  while  from  above  it  looks 
normal  with  the  exception  of  being  swollen  and  slightly  flexed. 

"Constitutional  symptoms  are,  as  a  rule,  not  marked,  though  some  cases 
show,  a  'leprous  fever'  early  in  the  disease.  Otherwise  the  cases  run  along 
uneventfully  for  many  years,  especially  if  they  will  take  treatment,  until,  as 
remarked  before,  they  die  of  some  other  disease."-^S.  D.  Barnes. 

The  bacilli  may  be  found  in  the  blood.  The  special  points  are 
the  dusky-red  hyperesthetic  macules  of  the  early  stage  and  the 
subsequent  development  of  anesthetic  areas. 

Treatment.  The  treatment  is  eminently  unsatisfactory.  A  few 
cases  of  apparently  spontaneous  recovery  are  recorded.  For  single 
nodules,  extirpation  is  advised.  Cleanliness  and  good  hygiene  are 
helpful.  Lepers  have  a  contentment'  which  makes  it  difficult  to 
secure  active  cooperation  in  hygiene  or  therapy.  This  peculiarity 
suggests  the  tubercular  hopefulness ;  in  leprosy  it  is  less  hope  than 
contented  resignation.  In  either  case,  lack  of  interest  in  thera- 
peutic measures  lessens  the  prospect  of  efficient  or  satisfactory 
treatment. 


LEPROSY  477 

Prognosis.  The  prognosis  is  hopeless  as  to  recovery,  but  the 
disease  is  extraordinarily  chronic,  lasting  for  four  to  thirty  years. 

Prophylaxis.  Segregation  should  be  compulsory  in  all  cases 
unless  the  relatives  can  show  that  they  can  make  provision  for 
complete  isolation  and  take  the  proper  care  of  the  patient. 

A  very  common  and  irrational  fear  of  leprosy  is  responsible 
for  occasional  injustice  in  the  treatment  of  lepers.  No  doubt  this 
terror  is  in  part  due  to  the  religious  history  of  leprosy,  and  in 
part  due  to  its  rarity  in  this  country.  Diseases  far  more  terrible 
and  far  more  contagious  arouse  little  or  no  fear,  partly  because 
they  are  common,  and  partly  because  there  is  a  tendency  to  con- 
ceal the  ravages  due  to  those  most  to  be  feared. 

Leprosy  is  feebly  contagious,  especially  in  skin  lesions.  Pa- 
tients with  nasal  secretions  are  most  dangerous.  In  countries 
where  leprosy  abounds,  leprous  men  and  women  have  healthy 
wives  and  husbands  and  children,  often  without  transmitting  the 
disease  in  any  form. 

Recently  successful  attempts  have  been  m.ade  to  inoculate  rab- 
bits with  leprosy  (Stanziale).  This  may  enable  such  study  of  the 
disease  as  is  necessary  to  better  methods  of  treatment  of  prophy- 
laxis. 


CHAPTER  XLIV 
TYPHOID  AND  TYPHUS 

TYPHOID  FEVER 

(Enteric  fever;  gastric  fever;  nervous  fever;  autumnal  fever;  enteromesenteric 
fever;  typhus  abdominalis  or  abdominal  typhus) 

Typhoid  fever  is  an  acute,  specific,  infectious,  mildly  contagious, 
febrile  affection  due  to  the  bacillus  typhosus  and  characterized 
anatomically  by  hyperplasia  and  ulceration  of  Peyer's  patches  and 
other  lymphoid  tissues ;  and  clinically  by  insidious  prodromes,  epis- 
taxis,  headache,  stupor  and  delirium;  diarrhea  and  tympany;  a 
peculiar  rose-colored  eruption  upon  the  abdomen  appearing  in 
successive  crops,  rapid  prostration,  and  a  prolonged  course  ending 
by  lysis  and  a  slow  convalescence. 

Etiology.  The  exciting  cause  is  the  bacillus  typhosus  of  Eberth, 
found  in  the  lesions,  the  blood,  stools,  urine,  and  sputum  of 
patients.  The  disease  occurs  epidemically  and  sporadically.  It  is 
transmitted  by  the  excretions  and  soiled  linen  of  the  patient  or  of 
"typhoid  carriers,"  and  gains  entrance  through  the  alimentary 
tract  by  contaminated  water,  ice,  milk,  shell-fish,  and  oysters 
grown  on  beds  polluted  by  sewage,  uncooked  vegetables  grown 
on  infected  soils  and  foods  contaminated  by  flies.  It  is  most  fre- 
quent during  late  summer  and  early  autumn. 

The  predisposing  causes  include  lesions  of  the  ninth  thoracic 
to  the  second  or  third  lumbar  vertebrae.  Lesions  of  the  cervical 
region,  either  vertebral  or  muscular,  and  lower  rib  lesions  are  to 
be  considered.  Lessened  mobility  of  the  dorso-lumbar  region  is 
constant. 

Pathology.  Typical  typhoid  ulcers  have  the  following  characteristics :  They 
lie  in  the  longitudinal  axis ;  the  edges  are  thin  and  undermined ;  are  located  in 
the  last  three  feet  of  the  ileum,  and  are  most  numerous  near  the  ileo-colic  valve; 
show  a  tendency  to  perforate  but  do  not  cause  constriction  after  they  have 
healed.  In  recovery  the  ulceration  is  replaced  by  granulation  tissue,  the  mucous 
membrane  extends  inward  over  it  and  the  ulcer  is  healed,  leaving  a  smooth, 
diffusely  pigmented,  brownish  or  slate-colored  scar.  The  gland  structure  is  not 
regenerated.  This  stage  is  usually  associated  with  the  fourth  week  of  the  fever. 
The  mesenteric  glands  undergo  similar  infiltration,  enlargement,  and  softening 
but  seldom  rupture  or  ulcerate.  The  mucous  membranes  of  the  entire  body, 
as  well  as  intestinal  tract,  undergo  catarrhal  changes. 

Abortive.  Convalescence  is  established  within  ten  days  or 
two  weeks  after  an  abrupt  onset  with  marked  symptoms.  Under 
proper  conditions,  this  type  or  the  next  should  be  the  only  form 
with  which  we  are  acquainted.  When  called  after  the  disease  has 
become  well  fixed,  the  more  serious  cases  may  be  met. 

478 


TYPHOID  FEVER  479 

Mild  typhoid  (typhus  levis)  is  marked  by  moderate  fever, 
slight  diarrhea,  and  few  or  no  nervous  symptoms. 

Ambulatory  (walking  typhoid  fever)  is  a  mild  type  with  symp- 
toms so  slight  as  often  to  be  disregarded  by  the  patient.  He  may 
come  to  the  physician  complaining  of  dull  persistent  headache 
and  increasing  weakness.  This  type  sometimes  terminates  fatally 
by  sudden  perforation  or  hemorrhage. 

Grave  forms  include  those  in  which  there  is  sudden  onset  with 
pronounced  pulmonary,  toxic,  gastro-intestinal,  renal  or  cerebro- 
spinal symptoms. 

Diagnosis.  In  the  typical  case  the  following  symptoms  occur: 
During  an  incubation  period  of  a  few  days  to  two  or  three 
weeks,  there  is  an  insidious  onset  with  general  malaise,  vertigo, 
chilliness,  disordered  digestion,  epistaxis,  disturbed  sleep,  dull  oc- 
cipital headache,  depression,  and  increasing  weakness  which  compel 
the  patient  to  take  to  his  bed  toward  the  end  of  the  period.  The 
patients  are  unable  to  say  when  the  sy;nptoms  began.  During  the 
first  week  of  the  illness  the  temperature  rises -to  about  103°  F.  in 
the  evening.  The  tongue  is  sticky  and  moist.  Each  day  the  tem- 
perature rises  slightly  above  any  previous  point.  The  pulse  in- 
creases daily,  and  may  be  dicrotic;  the  malaise  becomes  more 
marked,  the  patient  is  listless  and  has  thirst,  nausea,  and  headache. 
Pressure  in  the  right  fossa  elicits  tenderness  and  gurgling,  and  the 
tongue  becomes  heavily  coated  with  a  white  fur.  There  may  be 
a  diarrhea  of  brownish  stools  or  constipation. 

At  the  end  of  the  first  week  the  temperature  in  morning  is 
about  103°  and  evening  104.5°  F.  Tympanites  is  marked.  The 
eruption  appears  upon  the  upper  part  of  the  abdomen,  chest  and 
back  as  five  to  twenty  small,  rose-colored  spots,  raised  slightly 
convex,  disappearing  upon  pressure  and  at  death.  These  last  from 
three  to  five  days  and  are  succeeded  by  another  crop.  They  may 
not  appear  until  the  twelfth  day  and  are  sometimes  absent.  Dur- 
ing the  second  week  the  temperature  may  rise  to  105°  F.  in  even- 
ings with  the  usual  morning  remission.  All  symptoms  are  exag- 
gerated ;  there  is  low  delirium.  The  tongue  coating  disappears  and 
the  tongue  resembles  raw  meat,  is  fissured,  and  covered  here  and 
there  with  dry,  bloody  mucus.  Sordes  cover  the  teeth  and  lips. 
The  spleen  reaches  its  maximum  enlargement.  The  "pea-soup'' 
stools  are  fluid,  offensive,  yellow,  may  be  streaked  with  blood  and 
are  from  three  to  fifteen  during  twenty-four  hours.  From  this 
time  hemorrhage  or  perforation  may  be  looked  for.  Stupor  and 
carphologia  are  grave  symptoms.  Abortion  is  liable  to  occur  in 
pregnant  women.  During  the  third  week  the  fever  becomes  remit- 
tent ;  prostration  is  extreme ;  the  respirations  are  shallow  and 
quickened ;  loss  of  flesh  is  noticeable ;  the  diarrhea  lessens.  All 
other  symptoms  begin  to  show   amelioration  and  convalescence 


480  DISEASES  DUE  TO  BACILLI 

begins,  or  the  typhoid  stage  becomes  more  marked,  there  is  hypo- 
static congestion  of  the  lungs  and  death. 

During  the  fourth  week  the  temperature  is  daily  decreasing  to 
normal  or  subnormal  in  the  morning.  The  appetite  is  voracious. 
The  apathy  disappears,  sleep  is  more  refreshing,  delirium  is  slight 
or  none,  the  pulse  is  more  full  and  strong,  and  the  spleen  is  much 
smaller. 

Convalescence  is  marked  by  great  debility,  emaciation,  extreme 
anemia,  severe  nervousness,  irritability  of  the  heart,  profuse  night 
sweats  and  loss  of  the  hair  in  women.  Bradycardia  is  frequent. 
Relapse  may  occur  about  the  tenth  day  of  convalescence  with 
nearly  all  the  symptoms  repeated  but  less  intense  than  the  orig- 
inal. Recrudescences  due  to  excitement  or  gastrointestinal  dis- 
turbances are  common. 

Intestinal  hemorrhage  is  the  most  frequent  and  critical  of  any 
complication.  It  is  indicated  by  a  sudden  decline  in  temperature 
to  the  normal  or  below,  frequently  followed  by  the  passage  of 
blood  by  stool.  It  is  usually  due  to  the  erosion  of  a  blood  vessel 
during  ulceration,  and  death  may  occur. 

Perforation  may. occur  in  third  or  fourth  weeks.  It  is  indicated 
by  sudden,  severe,  and  localized  pain  in  abdomen,  abrupt  fall  of 
temperature,  tympanites,  absence  of  abdominal  respiration,  in- 
creased hepatic  and  splenic  dullness,  hiccough,  and  signs  of  per- 
itonitis.   Death  is  probably  imminent. 

Peritonitis  without  perforation  is  not  necessarily  fatal.  Lobar 
pneumonia,  hypostatic  congestion  of  the  lungs,  and  bronchitis  are 
frequent.  Nervous  symptoms  include  headache,  drowsiness  and 
stupor  with  great  prostration,  deafness,  impaired  or  double  vision. 
In  the  coma  vigil,  the  patient  lies  perfectly  quiet  and  inattentive 
with  eyes  open.  He  can  be  aroused  but  speedily  relapses  into  semi- 
consciousness. 

Phlegmasia  alba  dolens ;  acute  nephritis ;  neuritis ;  jaundice ; 
ulcerations  of  the  larynx,  tongue  and  buccal  mucosa;  and  mixed 
infection  causing  anything  from  boils  to  meningitis  may  complicate 
typhoid  fever. 

The  sequelae  are  not  frequent.  They  include  the  "typhoid 
spine";  constipation,  cholelithiasis,  neurasthenia,  and  general  ill- 
health.  Occasionally,  paralyses,  neuritis,  chorea,  hyperesthesia, 
epilepsy,  orchitis,  edema  and  gangrene  of  the  uvula,  metrorrhagia 
and  well-marked  marasmus  follow  typhoid.  Alopecia  and  trans- 
verse markings  of  the  nails  are  due  to  the  malnutrition.  Acute 
confusional  insanity  is  more  frequent  after  typhoid  fever  than 
after  any  other  febrile  condition  except  influenza. 

The  urine  has  the  usual  febrile  characteristics.  Albumin  is 
varial)le.     Acetone  and  diacetic  acid  may  be  present.     Typhoid 


TYPHOID  PEVER  481 

bacilli  are  often  demonstrable,  Ehrlich's  diazo-reaction  is  present 
by  the  third  to  the  tenth  day.    It  may  never  appear. 

If  uncomplicated  by  preexisting-  cardiovascular  or  renal  condi- 
tions, the  blood  pressure  falls  below  normal  after  the  patient  takes 
to  bed.  From  the  end  of-the  first  week  a  gradual  fall  in  the  blood 
and  pulse  pressure  continues  until  convalescence  is  established. 

The  blood  is  characteristic.  A  fresh  smear  may  show  the  large 
phagocytic  cell  of  Mallory.  During  the  first  week  there  is  a  slight 
rise  in  the  number  of  red  cells  which  slowly  falls  until  a  marked 
anemia  is  present  by  the  time  convalescence  is  established.  Regen- 
eration begins  with  defervescence.  The  fall  may  be  accentuated 
during  the  fourth  week.  After  hemorrhage,  nucleated  reds  may 
be  found.  The  hemoglobin  runs  parallel  -with  the  number  of  red 
cells  but  returns  to  normal  more  slowly.  Blood-platelets  and 
fibrin  are  reduced.  For  this  reason  peritonitic  adhesions  are  not 
usually  serious  in  typhoid.  The  white  cells  are  slightly  increased 
at  first,  the  count  gradually  diminishing  to  about  5,000  per  cmm. 
A  decided  rise  after  a  cold  bath  is  not  unusual.  There  is  no  true 
leucocytosis  in  uncomplicated  typhoid.  Differential  count  shows 
polymorphonuclears  and  eosinophiles  diminished,  mononuclears 
and  lymphocytes  increased.  During  convalescence  there  is  mild 
eosinophilia,  and  degenerated  leucocytes,  leucocytic  shadows  and 
leucocytes  with  granules  of  glycogen  are  to  be  found.  Return  to 
normal  blood  picture  is  slow  an^  the  blood  retains  its  characteristic 
features  for  about  three  weeks  after  the  temperature  is  normal. 

The  Widal  reaction  is  usually  positive  during  the  second  week. 
Occasionally  it  is  positive  in  non-typhoid  patients,  and  occasionally 
it  remains  negative  during  the  course  of  disease  presenting  typical 
typhoid  course.    Repeated  tests  should  be  made  in  doubtful  cases. 

Hemorrhage  causes  an  acute  posthemorrhagic  anemia  with 
leucocytosis.  Perforation  or  pyogenic  infection  is  accompanied  by 
a  rising  leucocyte  count. 

The  stool  is  copious,  watery,  fetid,  like  "pea-soup,"  in  appear- 
ance, containing,  besides  the  fecal  matters,  bacilli  of  typhoid,  blood, 
shreds  of  mucous  membrane,  sloughs,  and  many  triple  phosphate 
crystals.  It  has  an  alkaline  reaction.  A  stool  frequently  tinged 
with  blood  is  sometimes  a  warning  of  coming  hemorrhage.  When 
hemorrhage  occurs  the  stool  is  black,  tarry  and  sticky,  and  the 
usual  chemical  tests  for  blood  are  positive. 

The  data  for  diagnosis  are  (1)  general  from  the  clinical  symp- 
toms, the  temperature  curve,  eruption,  peculiar  diarrhea,  and 
enlarged  spleen,  (2)  specific  by  isolation  of  the  typhoid  bacillus 
from  the  blood,  stools,  urine  and  rose-spots,  and  by  the  Gruber- 
Widal  reaction. 

The  disease  must  be  diagnosed  from  enteritis  with  an  irregular 
fever,  peritonitis,  acute  miliary  tuberculosis,  meningitis,  appendi- 


482  DISEASES  DUE  TO  BACILLI 

citis,  peritoneal  tuberculosis,  rightsided  salpingitis,  simple  contin- 
ued fever,  typhus  fever,  relapsing  fever,  trichiniasis,  and  crypto- 
genetic  septicopyemia. 

Treatment.  When  typhoid  fever  is  present  in  a  community,  its 
presence  should  be  suspected  in  any  individual  showing  the  char- 
acteristic prodromal  symptoms.  Treatment  inaugurated  at  this 
time  should  consist  of  thorough  correction  of  any  lesions  found  in 
the  lower  thoracic  spine  and  the  ribs.  The  ribs  should  be  raised 
freely  and  the  usual  spinal  rigidity  be  completely  removed.  Bony 
lesions  anywhere  in  the  body  should  be  corrected.  The  thorough 
examination  of  heart,  lungs,  liver,  spleen,  bowels,  urine  and  blood 
at  this  time  may  be  very  important  in  governing  the  later  care 
of  the  patient  and  in  preventing  complications.  The  Widal  test 
is  usually  negative  until  the  second  week,  but  the  test  should  be 
made  as  soon  as  possible  and  should  be  repeated  if  negative  each 
week  through  the  course  of  the  disease.  It  is  not  possible  to  make 
a  certain  diagnosis  of  typhoid  during  the  prodromal  stage,  but 
many  cases  presenting  the  prodromal  symptoms  and  receiving  cor- 
rect treatment  never  show  characteristic  symptoms  of  well-devel- 
oped typhoid.  Whether  true  typhoid  can  be  aborted  or  not  is  a 
question  which  cannot  possibly  be  answered  by  the  very  circum- 
stances of  the  case.  It  is  true  that  patients  presenting  prodromal 
symptoms  and  receiving  early  and  correct  treatment  rarely,  if  ever, 
succumb  to  the  disease. 

The  long  days  of  serious  illness  of  the  ordinary  type  of  typhoid 
too  often  cause  an  unwise  demonstration  of  vigorous  therapeutic 
measures  of  various  kinds.  The  use  of  whisky  and  other  alcoholic 
stimulants  or  any  other  drugs  is  urgently  contraindicated.  Almost 
infinitesimal  amounts  of  alcohol  may  exert  serious  influences  upon 
a  body  already  weakened  by  the  disease.  Even  the  alcohol  inhaled 
as  the  result  of  an  alcohol  rub  is  too  much  for  the  ordinary  patient. 
The  alcohol  rub  should  be  superseded  by  a  dry  rub  with  a  mod- 
erately rough  towel  and  by  mild  massage.  If  skin  stimulation  is 
urgently  desired  a  pepper  solution  or  mustard  water  may  be  used 
instead  of  alcohol  for  rubbing.  The  collapse  that  sometimes  fol- 
lows a  cooling  bath  can  be  avoided  by  exposing  only  a  small  area 
of  the  body  to  the  sponge  and  making  the  process  a  very  slow  one. 
A  sponge  bath  of  water  of  a  body  temperature  or  slightly  above 
reduces  the  fever  through  evaporation,  but  gives  little  or  no  shock. 

During  convalescence  treatments  for  the  correction  of  the 
"typhoid  spine"  should  be  given  once  to  thrice  each  week.  The 
various  accidents  of  convalescence  can  be  met  as  they  occur. 

Diet.  Liquids  are  usually  given.  Milk,  diluted  with  water  or 
lime  water,  is  an  old  stand-by.  About  three  pints  every  day  should 
be  given ;  if  curds  appear  in  the  feces  the  milk  may  be  peptonized. 
Whey,  sour  milk,  buttermilk,  broths,  albumin  water,  all  are  sub- 


TYPHOID  FEVER  483 

stitutes,  and  are  given  when  the  patient  cannot  take  sweet  milk. 
Recently  a  number  of  new  diets  have  received  commendation. 
These  include  the  "high  calory"  diet,  which  "includes  three  pints 
of  milk  with  one  of  cream,  two  to  eight  ounces  of  milk-sugar, 
eggs,  butter;  sometimes  cereals,  toast,  potato,  and  other  soft  foods 
are  given.  A  full  sugar  diet,  as  of  candy  alone,  is  based  upon 
the  immediate  absorption  of  sugar,  its  value  as  a  source  of  energy, 
and  the  fact  that  a  plentiful  carbohydrate  supply  lessens  the  danger 
of  acidosis. 

Rectal  feeding  may  be  necessary.  Three  or  four  times  each 
day  the  rectum  should  be  gently  washed  with  warm  salt  solution, 
or  with  a  weak  molasses  or  sugar  enema.  After  this  has  been 
voided  the  nutrient  enema,  of  3  or  4  ounces  peptonized  milk,  one- 
half  ounce  meat  juice,  and  either  the  yolks  of  two  eggs  or  an 
equivalent  amount  of  other  proteid,  should  be  slowly  injected.  The 
molasses  enema  has  received  much  praise;  it  gives  some  nutrition, 
relieves  meteorism,  and  appears  to  be  pleasant  in  after  effects. 

The  plentiful  giving  of  cool,  fresh  water  in  abundance  is  most 
helpful.  At  intervals  of  twenty  minutes  a  few  drops  may  be 
allowed  to  fall  upon  the  tongue,  and  this  will  be  swallowed  without 
the  patient's  being  disturbed. 

"If  your  judgment  will  permit  you  to  do  so,  correct  the  predisposing  spinal 
lesions  at  once ;  thus  restoring  normal  circulation  and  nutrition  to  the  bowel. 
Treat  other  spinal  conditions  as  you  find  them,  giving  slow  deep  treatment, 
relaxing  all  contractions  full  length  of  the  spine,  occiput  to  coccyx.  *  ♦  *  Give 
gentle  stimulative  treatment  to  the  spleen,  for  upon  the  early  activity  of  this 
organ  in  the  production  of  both  red  and  white  blood  cells  depends  the  speedy 
restoration  of  the  body  tissue.  The  neck  treatment  must  be  soothing,  gentle, 
relaxing,  deep,  and  not  of  long  duration." — Julia  E.  Foster. 

"Gentle  treatment  twice  or  three  times  a  day  at  first  usually  keeps  the  fever 
down  and  patients  always  give  evidence  of  its  grateful  effects.  *  *  *  The  relax- 
ing of  the  spinal  musculature  which  always  becomes  tensed  as  the  fever  increases, 
tends  to  avoid  the  congestions  of  spinal  areas  and  thereby  prevents  complica- 
tions and  keeps  the  bodily  functions  active.  The  treatment  also  greatly  relaxes 
the  high  tension  of  the  patient  due  to  fever  and  intoxication.  It  nrecludes  the 
call  for  a  nerve  sedative  and  frequently  induces  sleep  immediately  following. 
Typhoid  makes  such  pronounced  ravages  upon  the  nervous  system  and  osteo- 
pathic treatment  so  essentially  combats  this  effect,  that  the  rapid  convalescence 
of  a  case  brought  through  under  that  treatment  is  in  striking  contrast  to  the 
slow  recovery  where  other  means  are  employe^." — P.  M.  Peck. 

"The  patient  should  be  seen  at  least  three  times  a  day;  in  administering 
treatment  he  should  be  rolled  over  on  his  side,  the  attention  first  being  directed 
to  the  contracted  muscles  of  the  back,  the  relaxation  of  which  Is  best  accom- 
plished by  firm  inhibition  along  the  spinal  column  on  each  side,  and  then  by 
gently  springing  it,  which  if  continued  for  a  little  while  invariably  brings  relief. 

"In  the  first  stage  of  the  disease  or  during  the  first  week,  severe  headache  is 
nearly  alwaj'S  present.  This  can  generally  be  relieved  by  thorough  relaxation  of 
the  muscles  and  ligaments  of  the  neck  especially  the  ligamentum  nuchae.  *  *  * 
Tympanites  is  almost  always  present  especially  after  the  second  week,  and 
sometimes  in  such  an  aggravated  form  as  to  render  the  condition  most  serious. 
A  good  deal  of  the  gas  is  usually  gotten  rid  of  by  stimulation  over  the  splanch- 
nics ;  very  gentle  abdominal  manipulation  can  also  be  given,  but  this  should  be 


484  DISEASES  DUE  TO  BACILLI 

done  very  carefully.  If  those  means  should  fail,  a  small  rectal  tube  should  be 
used;  it  should  be  inserted  very  carefully  and  not  too  high." — T.  D.  Lockwood. 

"Mechanical  stimulation  of  the  liver  and  kidneys  is  called  for,  with  special 
attention  to  treating  the  ninth  to  twelfth  dorsal  vertebrae,  which  are  considered 
to  be  the  area  of  the  spine  most  closely  connected  by  nerves  with  the  portion  of 
the  small  intestine,  in  which  the  tj'phoid  germs  are  most  active,  and  quieting 
pressure  treatment  along  the  spine  to  relieve  the  tired  restless  feeling. 

"I  have  said  nothing  relating  to  correcting  vertebral  lesions  in  typhoid.  Ex- 
cepting such  corrections  as  will  take  place  when  we  have  relieved  the  pull  of 
unequally  contracted  muscles,  I  believe  it  best  to  defer  the  adjustment  of  spinal 
lesions  until  convalescence.  If  we  attempt  such  corrections  during  the  febrile 
stage  we  will  violate  our  principle  of  avoiding  all  strains  and  the  added  irrita- 
tion would  be  more  hkely  to  raise  the  fever  than  to  lower  it.  Our  treatment  of 
typhoid  would  be  far  from  complete  if  we  confined  our  activities  to  the  pro- 
ceedings already  mentioned.  Our  duty  to  the  public  can  only  be  fulfilled  by 
enforcement  on  our  part  of  all  hygienic  principles  which  are  of  service  in  pre- 
venting the  spread  of  the  disease." — R.  F.  Weeks. 

"The  first  step  in  the  treatment  is  to  confine  the  patient  to  bed,  regardless  of 
how  mild  the  symptoms  seem  to  be.  Correct  all  lesions  affecting  both  nerve 
and  blood  supply  to  the  infected  region  when  it  is  possible.  *  *  *  A  severe  or 
rough  treatment  is  contraindicated.  If  the  patient  has  a  high  temperature  and 
is  excitable  the  best  thing  is  to  get  the  muscles  thoroughly  relaxed  from  the 
occiput  down,  giving  especial  attention  to  the  splanchnic  region.  By  gently 
stretching  the  spine  and  securing  motion  between  each  vertebra  you  will  get 
satisfactory  results.  ♦  *  *  The  liver  and  spleen  should  be  given  careful  atten- 
tion, see  that  the  gall  bladder  is  thoroughly  emptied,  as  the  bile  has  a  beneficial 
effect  on  the  intestinal  tract.  The  kidneys  are  to  be  kept  active.  It  is  best  to 
use  a  saline  enema  at  the  first  visit  to  be  sure  the  bowels  are  thoroughly  emptied. 
Constipation  during  the  course  of  the  disease,  that  cannot  be  controlled  by  the 
treatment,  should  be  reheved  with  the  saline  enemas,  it  will  not  be  necessary 
to  use  them  ofteher  than  every  second  day.  If,  as  is  usually  the  case,  a  diarrhea 
is  present,  the  treatment  should  be  inhibitory.  The  manipulation  used  requires 
a  great  deal  of  judgment,  be  careful  not  to  overtreat  and  at  the  same  time  try 
to  get  results  with  each  treatment.  Unless  the  patient  is  critically  ill  or  is  hav- 
ing hemorrhages,  two  treatments  a  day  will  be  all  that  is  necessary,  a  few  cases 
will  require  more  than  this." — M.  J.  Carson. 

A  positive  prognosis  cannot  be  made.  Favorable  signs  are  con- 
stipation or  slight  diarrhea,  low  temperature  and  moderate  or  no 
delirium.  Unfavorable  symptoms  are:  obstinate  and  severe 
diarrhea,  high  temperature  appearing  early,  cardiac  exhaustion, 
marked  nervous  symptoms  with  coma  vigil  or  stupor,  nephritis, 
repeated  intestinal  hemorrhages,  and  a  great  reduction  in  the  blood 
platelets.  A  steadily  falling  blood  pressure  is  a  sign  of  great  dan- 
ger. The  prognosis  is  more  favorable  in  the  winter  than  in  the 
summer  and  in  children  than  in  adults.  Pregnancy  and  obesity 
give  a  bad  prognosis.  Complications  such  as  pneumonia,  pleurisy, 
meningitis,  otitis,  or  erysipelas  may  occur. 

Recovery  may  begin  at  almost  any  time.  Convalescence  is  longer 
the  greater  the  weakness  and  higher  the  fever.  Under  osteopathic 
care  convalescence  is  less  tedious. 

Death  results  from  exhaustion,  cardiac  failure,  or  some  compli- 
cation, and  usually  during  or  about  the  third  week  of  disease. 


PARATYPHOID  FBVER  485 

Prophylaxis.  Public  prophylaxis  is  partially  secured  by  main- 
taining good  drainage,  a  pure  and  uncontaminated  water  supply,^ 
and  control  of  flies. 

The  patient  must  not  be  allowed  to  infect  others.  Isolation  is 
best.  Disinfection  of  urine,  stools,  sputum  and  of  all  articles  which 
may  be  accidentally  contaminated  by  these  excretions  is  necessary. 
For  the  urine  use  equal  amounts  of  a  1 :20  solution  of  carbolic 
acid  and  urine  and  let  stand  for  two  hours.  For  the  stools,  mix 
with  at  least  twice  the  amount  of  carbolic  solution  and  let  stand 
for  several  hours.  Disinfect  bath  water  after  using  with  chloride 
of  lime,  one-half  pound  to  a  bath  of  200  quarts,  and  let  stand  for 
one-half  hour  before  allowing  to  run  into  sewer.  Sputum  should 
be  collected  in  tuberculosis  cups  or  upon  small  cloths  and  burned. 
Bed  and  personal  linens  should  be  soaked  for  two  hours  in  the 
carbolic  solution  before  leaving  the  room,  'then  sent  to  the  laundry 
to  be  boiled.  Dishes  should  be  boiled  before  sending  from  the 
room. 

The  nurse  should  wear  a  rubber  apron  and  rubber  gloves  when 
convenient,  and  these  sterilized  as  occasion  demands.  The  room 
should  be  thoroughly  disinfected  after  the  patient  has  recovered. 

There  seems  to  be  no  doubt  of  the  existence  of  "typhoid  car- 
riers," whose  alimentary  or  urinary  tracts  carry  the  bacilli,  but 
who,  for  some  reason,  are  not  greatly  affected  thereby.  In  such  car- 
riers, any  unclean  habit,  which  results  in  the  presence  of  even 
microscopical  amounts  of  their  fecal  material  upon  their  fingers, 
renders  them  a  source  of  considerable  danger.  The  remedy  is  easy 
— for  each  person  to  be  so  clean  in  habit  that  absolutely  no  fecal 
material  reaches  the  fingers ;  and  also  that  the  hands  be  thoroughly 
scrubbed  with  soap  and  water  after  every  defecation.  Surely 
these  are  nothing  more  than  reasonably  cleanly  precautions,  yet 
they  are  enough  to  protect  against  the  danger  of  typhoid  carrier 
— if  he  only  would  become  educated  into  the  habits.  When  a 
typhoid  carrier  is  a  cook,  and  has  unclean  habits  about  toilet  and 
hands  and  food  stuff,  then  the  danger  is  considerable.  Only  the 
forces  which  lie  within  the  normal  cells  of  the  normal  body  are 
able  to  combat  infections  so  constantly  and  so  insidiously  intro- 
duced into  the  body. 

Typhoid,  like  typhus,  should  be  considered  a  disgrace  to 
modern  civilization.  It  is  a  filth  disease,  absolutely.  Its  existence 
would  be  limited  to  those  now  suffering  from  it,  if  there  were  no 
avenues  by  means  of  which  the  excreta  could  reach  food  and  drink. 

PARATYPHOID  FEVER 

Paratyphoid  fever  is  an  acute  infectious  disease  similar  to 
typhoid  fever  but  of  a  milder  type.  It  is  caused  by  the  paratyphoid 
bacillus,  a  form  or  forms  intermediate  between  the  bacillus  typho- 


486  DISEASES  DUE  TO  BACILLI 

sus  and  the  bacillus  coH  communis.    It  agglutinates  with  cultures 
of  its  own  kind  but  not  with  those  of  the  typhoid  bacillus. 

Pathology.  There  are  no  special  intestinal  lesions  as  in  typhoid. 
There  may  be  irregular  and  atypical  ulcers  in  the  lower  eight  or  ten  centimeters 
of  the  ileum  but  these  are  not  confined  to  the  lymphoid  tissue  and  are  not  accom- 
panied by  enlargement  of  Payer's  patches  or  swelling  of  the  mesenteric  glands. 

Diagnosis.  The  symptoms  in  most  cases  resemble  typhoid 
fever  closely  but  it  is  of  shorter  duration,  the  premonitory  symp- 
toms are  absent,  prostration  is  early,  myalgia  is  more  marked, 
and  the  temperature  rises  more  rapidly.  In  the  gastro-intestinal 
form,  the  temperature  rises  rapidly  after  a  chill,  and  diarrhea  super- 
venes at  once.    The  fever  usually  terminates  by  crisis. 

Complications  are  mainly  purulent  arthritis  and  myositis. 

Diagnosis  is  by  the  serum  reaction  only.  Both  species  of  bac- 
teria must  be  employed  in  the  test.  The  clinical  symptoms  of  vom- 
iting, epigastric  pain,  and  marked  prostration  are  dominant  fea- 
tures.   Cultures  may  be  obtained  from  the  blood,  urine  and  feces. 

The  treatment  is  the  same  as  for  typhoid  fever.  No  doubt 
many  of  the  "aborted"  cases  of  typhoid,  in  which  the  diagnosis 
rests  upon  symptoms  alone,  are  really  of  this  fever. 


TYPHUS  FEVER 

(Contagious  fever;  ship  fever;  jail  fever;  camp  fever;  exanthematous  typhus; 
Brill's  disease;  petechial  typhus;  spotted  or  putrid  fever) 

Typhus  fever  is  a  comparatively  rare,  acute,  specific,  epidemic, 
very  highly  contagious,  febrile  disease  characterized  by  sudden 
invasion,  rapid  rise  in  temperature,  pains  in  the  head,  back,  and 
limbs,  the  appearance  on  the  fifth  day  of  a  macular  and  petechial 
eruption,  low  muttering  delirium,  a  heavy,  drunken  expression,  a 
musty  odor,  and  a  crisis  about  the  fourteenth  day. 

Etiology.  The  specific  organism  is  the  bacillus  typhi-exanthem- 
atici  (Plotz).  The  predisposing  causes  are  filth  and  overcrowding. 
It  is  rare  in  the  United  States  except  in  seaports.  It  has  appeared 
in  Europe  during  this  war.  It  is  transmitted  by  contact,  fomites, 
and  human  body-lice,  probably  the  respiratory  secretions,  and  it  is 
infectious  throughout  the  disease  and  convalescence.  The  incu- 
bation period  is  from  a  few  hours  to  two  weeks,  usually  twelve 
days,  with  malaise  a  day  or  so  before  invasion. 

Diagnosis.  The  onset  is  sudden  with  chill  and  pains  in  back, 
limbs  and  head ;  temperature  reaching  104°  F.  within  a  few  days ; 
pulse  frequent,  100  to  140,  bounding,  often  dicrotic ;  the  usual  fever 
symptoms;  tongue  with  a  thick  white  !ur  later  becoming  brown; 
bowels  cqnstipated ;  conjunctivae  injected ;  pupils  contracted,  "fer- 
rety eye";  face  with  a  uniform  deep,  dusky  flush  and  glazed  skin, 


TYPHUS  PBVBR  487 

expression  dull,  heavy,  and  apathetic ;  early  prostration ;  and  noisy 
delirium.  / 

As  the  disease  progresses,  the  ternperature  continues  to  rise; 
the  pulse  becomes  small  and  weak;  a  pungent  musty  or  mousy 
odor  appears;  the  teeth  become  covered  with  sordes,  and  the  pros- 
tration is  extreme. 

Eruption.  On  the  fifth  to  the  seventh  day  there  appears  a 
"mulberry  rash"  over  the  whole  body  except  the  face.  Distinct 
papular  rose-spots  which  do  not  disappear  on  pressure  nor  after 
death,  appear  first  upon  the  abdomen,  and  constantly  increase  over 
the  body  for  forty-eight  hours.  Some  of  these  may  become  hem- 
orrhagic. During  the  second  week  the  typhoid  state  comes  on 
rapidly  with  low  muttering  delirium,  ataxic  symptoms,  subsultus, 
tremors,  carphologia,  dilated  pupils,  and  perhaps  bronchial  symp- 
toms. Coma  vigil,  retention  of  urine,  paralysis  of  the  sphincters, 
and  death  may  occur. 

About  the  fourteenth  day  the  patient  sinks  into  a  sound  sleep, 
the  temperature  falls  rapidly,  there  is  profuse  sweating,  a  critical 
diarrhea,  and  an  abundance  of  urates  in  the  urine,  after  which  the 
patient  gains  strength  rapidly.  The  spots  pass  through  gradations 
in  color  to  branny  desquamation. 

The  duration  of  the  disease  is  from  six  to  fifteen  days.  Ex- 
tremely mild  cases  may  have  slight  fever,  no  delirium  and  con- 
valescence established  by  the  tenth  day.  Malignant  or  typhus 
siderans  is  very  severe  from  the  onset  and  death  occurs  in  two  or 
three  days. 

The  complications  may  include  retention  of  urine,  gangrene  of 
extremities  or  bed-sores;  hypostatic  congestion  of  the  lungs,  bron- 
chitis and  broncho-pneumonia.  Parotid  bubo  and  pyemic 
abscesses,  thrombosis  of  the  femoral  vein,  meningitis  and  nephritis 
are  rare. 

The  heart  shows  the  efifects  of  the  poison  early.  An  abnormally 
slow  pulse  (50  to  30)  is  a  bad  sign.  The  spleen  is  enlarged  but 
not  tender.  The  urine  has  the  usual  febrile  characteristics.  The 
blood  changes  are  not  characteristic. 

Treatment.  Isolation  and  disinfection  of  clothing  and  excreta 
are  imperative.  Put  the  patient  to  bed,  in  the  open  air  if  possible. 
An  experienced  nurse  should  be  constantly  present. 

The.  position  of  the  patient  should  be  changed  from  time  to 
time  to  prevent  hypostatic  congestion.  Adjustment  of  the  entire 
spine  from  occiput  to  coccyx  is  necessary,  paying  particular  atten- 
tion to  the  relationships  between  head  and  atlas  and  neck  and 
inferior  maxillary.  Stimulating  treatment  along  the  spine  and  to 
the  heart  may  be  indicated. 


488  '     DISEASES  DUB  TO  BACILLI 

No  solid  food  is  permitted.  Liquids  should  be  used  as  plenti- 
fully as  the  assimilative  powers  will  admit.  Milk,  milk  and  soda 
water,  broths,  and  albumin  water  may  be  used. 

The  Prognosis  depends  upon  age,  temperature,  frequency  of 
pulse,  early  stupor  and  severity  of  symptoms.  Mortality  of  the 
young  is  slight,  in  those  past  middle  life  it  is  high.  Death  occurs 
during  the  second  week  from  toxemia;  during  the  third  mainly 
from  pneumonia.    Second  attacks  are  very  rare. 

Prophylaxis.  Keep  the  community  in  a  hygienic  condition,  pre- 
vent overcrowding,  and  look  to  the  condition  of  immigrants.  The 
existence  of  typhus  fever  in  any  city,  or  camp,  or  in  any  other 
place,  as  an  epidemic,  is  a  disgrace.  Only  a  most  inexcusable  lack 
of  attention  to  the  simplest  laws  of  hygiene  permits  the  continued 
existence  of  this  disease.  Sporadic  cases  may,  and  no  doubt  do, 
occur,  in  the  absence  of  serious  neglect  of  sanitary  precautions; 
this  is  especially  true  of  seaport  towns,  and  of  places  where  the 
populations  are  frequently  changing.  But  the  typhus  epidemic 
has  no  place  in  a  civilized  community. 


CHAPTER  XLV 
INFLUENZA,  PERTUSSIS  AND  DIPHTHERIA 

INFLUENZA 

(I^a  grippe;  grip;  contagious  catarrh;  epidemic  or  catarrhal  fever) 

An  acute,  specific,  infectious,  highly  contagious  disease,  occur- 
ring sporadically,  epidemically,  and  pandemically,  characterized  by 
fever,  by  protean  symptoms  affecting  mainly  the  res'piratory,  diges- 
tiye  and  nervous  systems,  by  muscular  pains,  and  by  a  prolonged 
prostration  out  of  all  proportion  to  the  intensity  of  the  fever. 

Etiology.  It  is  caused  by  the  bacillus  influenza  of  Pfeiffer, 
present  in  the  nasal  and  bronchial  secretions.  The  bacilli  persist 
after  the  severe  symptoms  have  subsided.  It  attacks  oftenest 
adults  between  the  ages  of  twenty  and  forty.  One  attack  seems 
to  predispose  to  subsequent  attacks.  Lowered  vitality  from  poor 
food,  fatigue,  exposure,  old  age,  bad  sanitation,  or  bony  or  muscular 
lesions  anywhere  in  the  body  are  predisposing  factors.  Lesions 
involving  the  midthoracic  region  are  almost  invariable.  The  in- 
cubation period  is  from  one  to  six  days,  oftener  three  to  four. 

Diagnosis.  The  onset  is  sudden,  marked  by  chill,  temperature 
which  rises  abruptly  to  102°  to  104°  F, ;  quick  compressible  pulse; 
sneezing;  injected,  watery  eyes;  severe  frontal  headache  and  back- 
ache; coryza  and  catarrh  of  the  upper  air  passages;  and  marked 
weakness.  In  mild  cases,  defervescence  occurs  by  lysis  or  crisis; 
sometimes  a  secondary  rise  occurs  from  the  third  to  seventh  day ; 
the  depression  and  debility  following  is  out  of  all  proportion  to 
the  fever  and  persists  for  a  cc5nsiderable  time. 

In  the  severer  cases,  after  the  first  few  days  the  symptoms  may 
group  themselves  so  that  an  attack  may  be  said  to  be  of  a  respira- 
tory, gastro-intestinal,  nervous  or  febrile  type  according  tp  the 
predominating  organs  attacked;  or  one  group  of  symptoms  may 
quickly  merge  into  another. 

The  respiratory  type  is  marked  by  paroxysmal,  violent  cough, 
after  which  bronchitis  or  broncho  or  croupous  pneumonia  may 
develop.  The  pneumonias  are  especially  apt  to  develop  in  the 
elderly  or  in  infants  and  are  often  fatal. 

The  gastro-intestinal  type  is  ushered  in  by  nausea  and  vomit- 
ing, anorexia,  epigastric  pain,  profuse  diarrhea,  prostration  amount- 
ing to  collapse,  and  sometimes  jaundice  and  enlargement  of  the 
spleen. 

In  the  nervous  type  the  initial  pains  are  more  severe,  there 
may  be  delirium,*and  after  defervescence  the  heart  becomes  slow 

489 


490  DISEASES  DUE  TO  BACILLI 

or  irregular,  with  sometimes  anginoid  pain.  Great  depression  and 
insomnia  follow.  Meningitis  or  encephalitis  may  be  found  post- 
mortem. 

In  the  febrile  type  there  is  continued  fever  with  delirium,  dry, 
brown  tongue  and  other  symptoms  of  the  typhoid  state. 

The  complications  form  a  long  list:  any  form  of  nervous  dis- 
order as  epilepsy,  myelitis  or  degeneration  of  the  cord,  neuritis, 
neuralgia,  insanity;  acute  otitis  media;  conjunctivitis;  functional 
or  organic  cardiac  disorders;  pneumonias  of  various  types  and 
pleurisy ;  nephritis ;  arthritic  pains ;  and  cutaneous  rashes. 

The  sequelae  are  also  numerous,  the  most  common  being  phthi- 
sis, chronic  gastro-intestinal  catarrh,  lymphatic  enlargement,  per- 
sistent headache,  neuralgia,  insomnia,  neuritis,  neurasthenia,  mel- 
ancholia, mania,  and  confusional  insanity. 

The  history  of  a  previous  attack  or  the  presence  of  an  epidemic 
are  leading  factors  in  diagnosis. 

The  spinal  examination  shows  an  extremely  contracted  mus- 
culature with  bony  or  other  lesions  anywhere  from  occiput  to 
coccyx.  The  region  in  the  neighborhood  of  the  fourth  thoracic 
spines,  following  around  to  the  third,  fourth  and  fifth  ribs,  is 
practically  always  subject  to  hypersensitiveness  and  pronounced 
muscular  tension,  both  of  the  spinal  and  the  intercostal  muscles. 

The  sputum  is  greenish  yellow  with  coin-like  lumps,  scanty  at 
first,  profuse  and  purulent  later. 

The  bacillus  influenza,  a  slender  rod  staining  readily  with 
ordinary  aniline  dyes  and  growing  only  on  blood  streaked  serum,  is 
found  in  the  moist  respiratory  secretions,  less  commonly  in  the 
lung,  heart,  or  central  nervous  system  but  rarely  in  blood.  The 
contagion  is  carried  by  the  moist  nasal  and  bronchial  secretions. 
The  blood  and  urine  show  few  changes. 

Treatment.  Rest  in  bed  is  imperative  even  in  mild  cases  and 
should  be  continued  for  a  day  or  two  after  the  temperature  is 
normal  to  avoid  any  risk  of  relapse  or  complications.  The  sputum 
and  nasal  secretions  must  be  disinfected.  The  manipulative  treat- 
ment varies  with  the  symptom-group  predominating.  Careful  re- 
laxation of  the  tense  muscles  along  the  entire  spine,  very  careful 
correction  of  any  bony  lesions,  inhibition  of  the  posterior  cervical 
areas  to  control  the  fever  are  some  necessary  factors.  Stretching 
with  internal  and  external  rotation  of  the  legs  gives  relief. 

At  the  inception  a  thorough  sweat  and  enema  are  beneficial. 
For  the  rhinitis,  the  treatment  given  under  this  subject  should  be 
employed.  Gastro-intestinal  symptoms  may  be  met  with  the  treat- 
ment given  under  acute  gastritis ;  cardiac  symptoms  should  receive 
the  treatment  given  under  acute  endocarditis. 

The  diet  should  be  liquid  during  the  height  ^f  the  fever,  then 
semisolid  with  plenty  of  water.     Cooling  drinks  are  good  during 


WHOOPING  COUGH  491 

the  attack.  During  convalescence,  the  food  should  be  plenty  and 
nutritious.  If  the  temperature  is  high,  tepid  sponging  and  the 
ice-cap  to  the  head  are  indicated.  If  constipated  at  the  onset,  give 
enema.  Frequent  inhalations  of  steam  may  relieve  the  naso- 
pharyngeal and  bronchial  symptoms.  Hot  fomentations  to  the 
back  aid  in  relieving  the  distress.  If  diarrhea  is  present  use  the 
hot  fomentations  to  the  abdomen  also.  The  patient  must  be  pro- 
tected from  changes  of  the  weather,  especially  those  at  either 
extremes  of  life  or  those  having  chronic  disease.  During  con- 
valescence, great  care  must  be  given  to  avoid  relapse  or  sequelae. 
Rest,  nutritive  diet,  and  change  of  air  is  advisable. 

Prognosis.  In  uncomplicated  cases  the  prognosis  is  good  for 
recovery  except  in  the  elderly  and  in  infants.  Relapses  are  com- 
mon. 

Prophylaxis.  This  is  best  secured  by  isolation  of  the  patient 
and  disinfection  of  the  bodily  discharges.     It  is  not  quarantined. 

Persons  suffering  from  influenza  should  avoid  crowds,  and  they 
should  not  come  into  close  contact  with  other  persons.  Certainly 
kissing  should  be  tabooed  at  this  time.  It  is  particularly  desirable 
that  children  should  be  protected  from  infection.  The  person  who 
suffers  from  influenza  is  also  particularly  liable  to  contract  certain 
other  diseases,  notably  tuberculosis  and  pneumonia;  so,  for  his 
own  sake  as  well  as  for  the  sake  of  those  who  might  suffer  through 
him,  he  should  very  carefully  avoid  mixing  with  his  fellows  during 
the  attack. 

WHOOPING  COUGH 

(Pertussis;  tussis  convulsiva) 

Whooping  cough  is  a  specific,  epidemic,  infectious,  contagious 
disease  affecting  the  respiratory  organs  and  attended  by  a  peculiar 
paroxysmal  cough  known  as  the  whoop. 

Pertussis  is  highly  contagious,  being  carried  by  direct  contact 
and  by  fomites,  attacking  principally  children  between  the  first 
and  second  dentitions.  The  Bordet  and  Gengou  bacillus  is  the 
specific  cause.  This  is  found  in  the  sputum  most  abundantly  dur- 
ing the  first  week,  the  most  infectious  period,  and  becomes  grad- 
ually less.  One  attack  usually  confers  immunity.  The  incubation 
period  is  from  seven  to  ten  days.  The  patient  may  be  considered 
noninfectious  five  weeks  after  the  first  whoop. 

Lesions  of  the  cervical  and  upper  dorsal  vertebrae  and  of  the 
first,  second  and  third  ribs,  affecting  the  vagi,  the  phrenic,  the 
sympathetic,  the  recurrent  laryngeal  or  the  vasomotor  nerves  pre- 
dispose to  the  disease. 

Diagnosis.    Three  stages  of  the  disease  are  usually  recognized. 


492  DISEASES  DUE  TO  BACILLI 

Catarrhal.  The  invasion  is  either  insidious  or  well-marked 
with  an  initial  temperature  of  100°  to  102°  F.,  attended  by  symp- 
toms of  ordinary  naso-laryngo-bronchial  catarrh  and  a  loose  cough 
of  an  incessant  character.  After  one  or  two  weeks,  instead  of 
improving,  the  cough  becomes  worse  and  the  second  stage  appears. 

Spasmodic.  The  cough  becomes  paroxysmal,  consisting  of  a 
succession  of  fifteen  or  more  short,  rapid,  expiratory  puffs  with 
no  intervening  inspiration,  immediately  followed  by  a  deep,  loud 
inspiration.  This  is  the  characteristic  whoop  and  is  due  to  the 
partial  closure  of  the  glottis.  Each  paroxysm  is  composed  of  three 
or  more  such  spells,  the  last  one  followed  by  the  expectoration  of 
a  small  plug  of  mucus  or  by  vomiting.  During  the  paroxysm  the 
facies  presents  a  swollen,  dusky  appearance,  eyeballs  protruding, 
reddened  eyes,  and  puffy  pinkish  lids.  The  body  is  bent  forward, 
and  the  patient  is  perfectly  helpless.  Urine  and  feces  may  be  passed 
involuntarily.  Cyanosis  may  occur  from  the  strain.  The  child 
knows  the  attack  is  coming  by  a  sensation  of  tickling  in  the  larynx, 
tries  in  every  way  to  stop  it  and  runs  frightened  to  its  nurse  or 
some  object  for  support. 

Emotion,  irritation  of  the  throat  by  dust  or  a  tongue  depressor, 
even  swallowing,  and  especially  accumulations  of  mucus  in  the 
lar}'nx  provoke  an  attack.  Between  paroxysms  the  child  is  appar- 
ently well.  If  vomiting  frequently  occurs  he  becomes  anemic  and 
wasted. 

During  the  severe  cough  petechiae  of  the  forehead,  ecchymosis 
of  the  conjunctivae,  epistaxis,  bleeding  from  the  external  auditory 
meatus  or  from  the  frenum  of  the  tongue  and  occasionally  hemop- 
tysis may  occur.  Ulcer  of  the  frenum  of  the  tongue  is  common. 
The  number  of  paroxysms  varies  from  four  to  eighty  or  more  in 
twenty-four  hours.  This  stage  lasts  three  to  six  weeks,  usually 
about  four  weeks. 

Terminal.  The  paroxysms  occur  at  longer  intervals,  are  of 
shorter  duration  and  of  less  intensity,  the  catarrhal  symptoms  are 
more  marked,  the  expectoration  becomes'  thinner,  fluid,  muco- 
purulent, and  looser.  This  state  lasts  from  a  week  to  several 
months.    "Habit  cough"  may  follow. 

Convalescence  varies  greatly,  is  generally  slow  and  the  patients 
are  particularly  liable  to  tuberculosis  at  this  time. 

The  most  common  complications  are:  convulsions  in  infants, 
cerebral  hemorrhage,  broncho-pneumonia,  acute  dilatation  of  the 
right  ventricle,  tuberculosis  and  emphysema.  The  disease  may 
result  in  cardiac  valvular  lesions,  hernia,  or  pigeon-shaped  chest 
from  the  strain.     Chronic  bronchitis  and  asthma  may  follow. 

The  blood  shows  an  early  leucocytosis  ranging  from  20,000  to 
40,000  cells  per  cubic  millimeter,  lymphocytes  being  35  to  55%  ; 
polynuclear   cells    relatively    decreased;    eosinophiles,    normal    or 


WHOOPING  COUGH  493 

diminished.  The  hemoglobin  and  red  cells  bear  no  direct  relation 
to  the  leucocytosis. 

The  urine  has  a  high  specific  gravity,  1022  to  1023;  is  light 
yellow;  contains  much  uric  acid;  and  may  contain  albumin  and 
sugar  as  a  result  of  the  physical  strain. 

The  diagnosis  is  made  by  the  characteristic  whoop  in  the 
second  stage.  If  no  real  whoop  is  present,  the  swollen  face  and 
eyes,  the  ulcer  of  the  frenum  of  the  tongue  and  the  vomiting 
after  the  severe  cough  leave  no  doubt. 

Treatment.  Isolation  of  the  patient  in  a  well-ventilated,  sunny 
room  where  he  can  secure  fresh  air  day  and  night  is  essential. 
Children  exposed  to  infection  should  be  disinfected  and  isolated 
for  at  least  three  weeks  as  the  disease  cannot  be  diagnosed  in  the 
catarrhal  stage.    If  at  all  severe,  rest  in  bed  is  advised. 

If  the  physician  sees  the  patient  early  he  may  abort  the  dis- 
ease. Treatment  of  the  whole  respiratory  tract  with  correction  of 
vertebral  and  rib  lesions  and  relaxation  of  any  contracted  muscles 
should  be  given.  A  subluxated  atlas  and  axis  are  especially  harm- 
ful. Dr.  Still  considers  the  diaphragm  a  factor  in  the  spasm  and 
treats  it  as  well  as  the  phrenic  nerve  to  give  relief.  Subluxations  of 
the  first  and  second  ribs  produce  irritation -of  the  recurrent  laryn- 
geal nerve  and  hence  of  the  whole  larynx. 

"Children  who  play  and  sleep  out  of  doors  get  along  better.  For  the 
paroxysms  I  use  an  elastic  belt,  with  a  pad  over  the"  stomach.  Sometimes 
the  children  realize  its  comfort  and  refuse  to  have  it  taken  off.  Steam 
inhalations  may  give  relief;  sprays  I  find  useless.  A  spoonful  of  syrup  made 
of  sugar  with  lemon  or  pineapple  may  be  given  at  the  first  tickling  sensation." 
— Asa  Willard. 

The  diet  must  be  nutritious  and  easily  digested.  The  child 
should  be  warmly  clad  and  protected  from  drafts  of  air.  The 
excretory  systems  are  kept  in  active  condition  by  plenty  of  water 
and  diet.  Treat  the  various  symptoms  as  they  occur.  Relieve  the 
respiration  by  raising  the  upper  ribs  especially  those  over  the 
heart.    Treatment  throughout  the  vasomotor  area  is  indicated. 

Inhalations  of  steam  may  be  beneficial.  During  convalescence, 
the  child  must  be  carefully  watched  and  fed  as  broncho-pneumonia 
or  tuberculosis  is  apt  to  develop.  Change  of  air  is  often  of  benefit. 
Tonic  treatment  to  assist  in  restoring  the  respiratory  equilibrium 
and  to  increase  the  nutrition  of  the  child  is  urgently  demanded. 

Prognosis.  With  the  complications,  this  is  the  most  fatal  of 
the  acute  infections  under  five  years  of  age.  Infants  and  young 
children  should  receive  especial  care. 

Ordinary  uncomplicated  cases  are  favorable  for  recovery.  The 
prognosis  depends  upofi  the  age  and  strength  o!  the  patient,  the 
severity  and  number  of  paroxysms,  and  the  presence  or  absence  of 
complications.    No  recurrence  is  to  be  expected. 


494  DISEASES  DUE  TO  BACILLI 

Death  is  due  to  spasm  of  the  glottis  or  to  extensive  subdural 
hemorrhage,  occurring  chiefly  in  the  children  of  the  poor  and  in 
delicate  infants. 

Sequelae  are  rather  frequent  especially  in  the  poorly  nourished. 
Careful  watchfulness  on  the  part  of  the  physician  and  the  nurse 
will  do  mubh  to  prevent  these  results  if  treated  when  the  slightest 
symptoms  of  overstrain  are  first  noticed. 

Prophylaxis.  This  consists  in  isolation,  disinfection  of  sputum 
and  final  fumigation  of  the  premises.  It  is  not  quarantined. 
Children  should  be  protected  from  danger  of  infection,  by  keeping 
them  away  from  cases  of  whooping  cough,  and  also  by  having 
their  general  health  kept  up  by  sane  and  wholesome  living  through- 
out childhood. 

DIPHTHERIA 

(Putrid  sore  throat;  malignant  ulcerous  sore  throat;  malignant  quinsy; 
membranous  angina) 

Diphtheria  is  an  acute,  specific,  infectious,  epidemic  and 
sporadic,  contagious  constitutional  disease  occurring  chiefly  among 
children,  and  associated  with  grave  throat  symptoms,  general 
symptoms  of  fever,  glandular  enlargement,  and  great  prostration, 
and  the  formation  of  a  false  membrane  or  fibrinous  exudation  on 
mucous  and  abraded  surfaces  and  often  followed  by  paralyses  in 
various  situations. 

Etiology..  The  exciting  cause  is  the  bacillus  diphtheriae  of 
Klebs  and  Loeffler  which  produces  a  toxalbumin  the  absorption 
of  which  produces  the  symptoms  of  the  disease.  It  is  associated 
with  other  organisms  the  most  important  of  which  is  the  strepto- 
coccus pyogenes. 

The  predisposing  factors  are  childhood,  ages  from  two  to  ten 
years;  naso-pharyngeal  catarrh;  individual  susceptibility;  and 
structural  perversions  of  the  neck,  clavicle,  upper  ribs  and  ver- 
tebrae. Muscular  contractions  of  the  scaleni  and  the  large  neck 
muscles  disturb  the  relations  of  the  first  rib  with  the  clavicle  and 
the  vertebrae,  thus  interfering  with  the  size  of  the  thoracic  inlet 
and  the  relations  of  the  contained  important  structures.  First  rib 
subluxations  are  nearly  always  found.  The  bacteria  are  found  in 
the  exudation  and  secretion  of  the  fauces  and  the  saliva. 

The  usual  modes  of  infection  are  from  one  person  to  another 
by  contact  or  by  infected  articles.  (The  bacillus  may  retain  vital- 
ity for  months.)  Diphtheria  carriers  are  persons  who  present  no 
recognizable  signs  of  the  disease  yet  carry  the  bacillus  in  their 
throats.  They  may  spread  the  disease  widely.  Milk,  and  rarely 
other  foods,  may  carry  the  bacilli.  Accidental  infection  from  cul- 
ture or  through  animals  is  rare.  The  incubation  period  is  from 
one  to  five  days. 


DIPHTHERIA  495 

Diagnosis.  The  bacilli  are  cultured  from  the  throat,  and  these, 
with  the  characteristic  symptoms,  are  necessary  to  diagnosis.  The 
pharyngeal  is  the  most  common  type.  The  invasion  may  be  mild 
with  general  malaise  and  rigors  succeeded  by  a  moderate  fever, 
100°  to  103°  F.,  usually  falling  on  the  second  to  third  day;  pulse 
full  and  strong,  100  to  120;  anorexia;  stiffness  of  neck,  tenderness 
and  swelling  of  the  deep  faucial  glands  at  the  angles  of  the  jaw; 
a  slight  soreness  of  the  throat,  and  a  complaint  of  a  frequent 
desire  to  hawk  in  order  to  clear  the  throat.  On  inspection,  the 
fauces  and.  the  pharyngeal  mucous  membranes  are  found  red, 
swollen,  and  with  a  characteristic  glazed  appearance.  This  is  soon 
followed  by  whitish  patches  which  rapidly  coalesce  into  a  dirty 
white  membrane  upon  the  fauces  or  tonsil,  the  removal  of  which 
exposes  a  raw  bleeding  surface.  Both  tonsils  and  the  uvula  may 
be  greatly  swollen  and  spotted  with  exudate. 

By  the  third  day,  the  false  membrane  covers  the  tonsil,  pillars 
of  the  fauces,  and  perhaps  the  uvula  which  is  thick  and  edematous. 
The  growth  ceases  after  this  or  the  fourth  day.  The  tongue  is 
slightly  coated,  sometimes  with  more  or  less  exudate  upon  it. 
The  bowels  are  regular  or  diarrheic.  Prostration  is  marked.  After 
the  seventh  day,  the  throat  clears,  and  convalescence  begins  unless 
complications  intervene. 

Atypical  forms  are  many.  They  are  a  grave  danger  to  the 
community  by  remaining  undetected  and  thus  spreading  the 
malady.  The  Klebs-Loeffler  bacillus  may  be  cultivated  from  the 
throat.  No  local  membrane  may  appear,  a  simple  catarrhal  angina 
with  a  croupy  cough  being  the  only  symptoms.  In  other  cases 
the  tonsils  are  covered  with  a  pultaceous  exudate  but  not  a  con- 
sistent membrane.  Some  cases  present  only  symptoms  of  a  typical 
lacunar  tonsilitis. 

"Latent  diphtheria"  occurs  chiefly  in  hospital  practice  in  young 
persons  subject  to  wasting  diseases.  It  is  manifested  by  fever, 
naso-pharyngeal  catarrh  and  gastro-intestinal   disturbances. 

Nasal  diphtheria  is  usually  secondary  to  the  pharyngeal.  The 
main  symptoms  are  bloody,  offensive  discharge  from  the  nose, 
attacks  of  epistaxis,  a  nasal  twang  to  the  voice,  and  regurgitation 
of  food  and  drink  through  the  nose^  The  constitutional  reaction 
is  marked.    The  membrane  may  or  may  not  be  visible. 

Laryngeal  diphtheria  (membranous  croup).  Extension  to  the 
larynx  is  indicated  by  hoarseness  or  loss  of  voice,  a  brassy,  croupy 
cough,  noisy  and  stridulous  breathing,  obstructive  dyspnea,  and 
cyanosis.     The  membrane  may  appear  first  in  the  larynx. 

The  bronchial  form  has  all  the  symptoms  of  a  severe  capillary 
bronchitis.  The  membranes  after  reaching  the  bifurcation  speed- 
ily become  purulent. 


496  DISEASES  DUE  TO  BACILLI 

Malignant  form.  The  symptoms  are  all  severe  from  the  start. 
There  is  marked  prostration,  a  marked  tendency  to  hemorrhages, 
and  the  typhoid  state  develops  early  with  death  in  a  few  days. 

Complications  are  many.  Nephritis  is  the  most  common. 
Albuminuria  is  nearly  always  present  and  when  associated  with 
blood  and  epithelial  casts  and  scanty  urine  indicates  parenchyma- 
tous changes  of  the  kidney.  Uremia  may  develop  without  the 
presence  of  severe  throat  symptoms. 

Diffuse  erythema  is  common.  Occasionally  urticaria  and  pur- 
pura are  seen.  Membrane  formation  upon  external  wounds  some- 
times occurs.  Severe  ulceration  of  the  throat  may  follow  careless 
treatment. 

Cardiac  disturbances  are  constant.  A  murmur  is  heard  in 
94%  of  cases.  Rapid  action  with  gallop  rhythm  and  epigastric 
pain  and  tenderness  are  serious  symptoms.  Fatal  dilatation  may 
occur  as  late  as  the  sixth  or  seventh  week.  Cardiac  diseases,  espe- 
cially myocarditis,  are  most  common  during  the  second  and  third 
week. 

Capillary  bronchitis  and  broncho-pneumonia  are  frequently 
found  in  fatal  cases.  Otitis  media  occurs  by  extension  through 
the  Eustachian  tube.  Conjunctival  diphtheria  is  rare.  It  ipay 
occur  in  the  physician  or  nurse  from  receiving  expectorations  in 
the  eye  while  examining  the  throat  of  the  patient.  Meningitis, 
thrombosis,  and  septicemia  are  rare. 

The  sequelae  may  be  serious.  Post-diphtheritic  paralysis  is 
due  to  a  toxic  neuritis  and  is  the  most  common  sequela,  being 
present  in  10%  to  30%  of  cases.  It  may  appear  at  the  end  of  the 
first  week  but  usually  within  three  weeks  of  apparent  recovery. 
It  seems  to  be  more  frequent  when  antitoxin  is  used,  and  may 
appear  without  diphtheritic  symptoms,  from  preventive  doses. 

Anesthesia  of  the  pharyngeal  mucosa  with  paralysis  of  the 
pharyngeal  muscles  and  soft  palate  may  seriously  interfere  with 
deglutition  and  impair  the  voice. 

Loss  of  accommodation  of  the  eye  causes  squint  or  diplopia. 
Anemia  and  chronic  naso-pharyngeal  catarrh  may  follow  even  mild 
attacks. 

The  blood  pressure  is  subnormal  during  invasion,  bearing  a 
direct  relation  to  the  severity  of  the  faucial  attack.  Albuminuria 
does  not  cause  a  rise  in  pressure.  Steady  progressive  fall  in  pres- 
sure is  often  present  in  fatal  cases. 

The  urine  is  febrile.  Albumin  is  present  early.  Often  tube 
casts  and  renal  epithelium  can  be  found.  Bacilli  are  present  only 
when  the  diphtheritic  lesions  are  so  situated  as  to  communicate 
with  the  urinary  tract. 

Blood.  Hypercythemia  is  frequent.  It  may  reach  7,500,000 
cells.     With  the  drop  in  count,  nucleated  reds  and  polychromat- 


DIPHTHERIA  497 

ophilic  cells  are  seen.  During  convalescence  there  is  a  more  or 
less  severe  anemia  depending  upon  the  severity  of  the  toxemia. 
Specific  gravity  is  increased.  Hemoglobin  is  slightly  reduced. 
Leucocytosis  is  proportionate  to  the  severity  of  the  disease,  usually 
between  15,000  and  30,000  cells. 

The  polymorphonuclear  cells  are  increased,  there  may  be  a 
relative  or  actual  lymphocytosis,  and  the  eosinophiles  are  normal 
or  decreased.  Myelocytes  are  present,  3%  to  16%,  over  3%  being 
of  grave  prognostic  omen.  There  may  be  an  acidophilic  tendency. 
Leucocytic  shadows  are  common. 

Treatment.  The  present  antitoxin  method  of  treatment  is 
much  less  dangerous  than  the  older  medical  methods.  It  may 
even  be  advantageous  in  malignant  cases.  Its  value  diminishes 
steadily  with  the  course  of  the  disease.  In  order  to  prevent  dis- 
aster due  to  the  use  of  horse  serum  and  to  anaphylaxis,  if  antitoxin 
is  to  be  given,  an  extremely  small  dose  should  be  given,  and  the 
patient  watched  for  two  hours  or  more;  if  serious  effects  are 
produced,  no -further  attempt  should  be  made  to  use  the  serum. 
If  no  ill  effects  are  noted,  a  large  dose  should  be  given,  and  this 
should  be  sufficient.  At  any  time  greater  than  ten  days  after  anti- 
toxin or  any  other  preparation  of  horse  serum  has  been  injected, 
there  is  a  probability  of  sensitization,  and  no  more  serum  should 
be  injected,  except  with  very  careful  precaution. 

"The  treatment  of  diphtheria  by  osteopathic  methods  is  often  a  pleasure 
rather  than  a  trial  because  of  the  success  which  rewards  us  for  our  efforts. 

"There  has  been  considerable  discussion  by  the  members  of  our  profession 
regarding  the  methods  to  be  employed  in  successfully  overcoming  this  disease, 
and  many  have  expressed  the  view  that  since  antitoxic  serum  is  a  physiological 
remedy,  which  naturally  belongs  to  all  schools  of  healing,  it  should  be  employed 
by  the  osteopathic  physician  in  cases  of  diphtheria.  I  have  no  objection  to  the 
use  of  serum  therapy  by  those  members  of  the  profession  who  conscientiously 
feel  that  they  need  it  in  their  practice  to  secure  the  highest  measure  of  success. 
However,  I  feel,  on  the  other  hand,  that,  if  they  were  well  acquainted  with  the 
technic  of  the  methods  which  will  be  given  below,  they  would  not  feel  it  to 
their  advantage,  from  the  standpoint  of  success,  to  use  serum  injections  in  a 
single  case. 

"The  important  measures  illustrating  this  technic,  from  the  writer's  stand- 
point in  a  case  of  diphtheria  are :  First,  remove  any  influences  which  are 
interfering  with  good  circulation  and  nerve  control  in  the  region  of  the  throat, 
and  throughout  the  neck  generally,  by  properly  directed  adjustive  manipula- 
tion. Furthermore,  promote  the  best  possible  circulation  in  the  gastro-intestinal 
tract,  in  the  liver,  in  the  kidneys,  and  to  the  whole  vascular  system.  Second, 
cleanse  the  large  intestines  with  enemata,  and  if  there  is  material  in  the  stom- 
ach at  the  beginning  of  the  illness,  wash  out  the  stomach  with  the  stomach 
tube.  Each  day  thereafter  use  an  enema  as  a  routine  procedure.  Third,  stop 
all  food  and  give  nothing  but  water.  Let  the  patient  have  all  the  water 
desired,  either  hot  or  cool.  The  food  is  not  to  be  resumed  until  the  disease 
is  fully  under  control,  vindicated  by  the  return  of  the  temperature  to  the  normal 
and  the  disappearance  of  all  active  symptoms  of  the  disease.  Fourth,  the 
temperature  is  controlled  by  the  manipulation  and  by  hydrotherapy,  using  the 
full  tub  bath  if  necessary.  At  all  times  the  feet  should  be  kept  warm  and 
artificial  heat  should  be  supplied  to  the  feet  and  legs  when  necessary,  even  if 


498  DISEASES  DUE  TO  BACILLI 

the  temperature,  by  the  mouth,  is  somewhat  above  normal.  Ice  may  be  used 
over  the  throat  while  the  temperature  is  high,  and  may  be  replaced  by  hot 
applications  when  the  temperature  has  fallen  below  103  degrees  Fahrenheit. 
Sixth,  the  osteopathic  physician  should  resort  to  intubation  in  those  cases  which 
come  under  his  care  after  the  case  is  quite  advanced  and  the  membranes  cause 
an  extreme  interference  with  jespiration.  The  introduction  of  an  O'Dwyer 
tube  into  the  larynx  is  not  a  difficult  procedure,  and  used  in  those  severe  cases 
which,  on  account  of  the  unfavorable  constitutional  condition  of  the  patient 
and  the  rapidity  with  which  the  disease  may  progress  under  such  circumstances, 
may  develop  distressing  obstruction  to  the  breathing  before  the  remedial  agents 
which  have  been  mentioned  above  could  control  the  situation,  the  results  would 
be  highly  gratifying.  I  feel  that,  if  we  fully  understood  and  practiced  the 
treatment  of  diphtheria  on  the  basis  outlined  above,  our  results  would  be 
exceedingly  satisfactory,  and  we  would  never  feel  it  necessary  to  resort  to  anti- 
toxin at  any  stage  of  the  disease.  In  fact.  I  am  convinced  that  any  case 
which  can  be  cured  by  antitoxic  serum  can  be  cured — and  that  more  quickly 
and   satisfactorily — by   the   above  technic." — R.   D.   Emery. 

The  heart  action  must  be  carefully  watched.  Each  day  pay 
particular  attention  to  the  upper  dorsal  vertebrje  and  ribs.  Clav- 
icles, ribs,  and  sternum  must  be  in  proper  relationship.  The  occip- 
ito-atlantoid  articulation,  the  hyoid,  and  the  inferior  maxillary  must 
be  watched  daily. 

"Search  out  the  contracted  muscles   and  the  cause  of  their  contraction. 
Examine  and  know  the  condition  of  the  kidneys  and  bladder.     Know  that  the 
.  ureters  are  freed  from  all  obstructions  by  pressure  or  otherwise  and  are  carry- 
ing out  their  normal  functions." — A.  T.  Still. 

For  the  pain  around  the  throat,  careful  treatment  of  the  cer- 
vical muscles  and  the  glands,  and  hot  applications  to  the  angle  of 
the  jaw  are  a  comfort.  In  the  laryngeal  form,  inhalations  of  hot 
water  vapor  with. ice  pellets  to  suck  afford  relief.  If  suffocation 
is  threatening,  intubation  or  tracheotomy  may  be  necessary. 

The  mouth  must  be  washed  with  Dobell's  solution  or  normal 
salt  solution  every  hour  to  keep  the  mouth  and  pharynx  as  clean 
as  possible. 

Nasal  cleansing  is  especially  necessary  in  the  nasal  form.  Nor- 
mal salt  solution  (1  teaspoonful  to  the  pint  of  water),  saturated 
boric  acid  solution,  or  Dobell's  are  used. 

Convalescence  requires  nourishing  foods,  fresh  air  and  stim- 
ulating treatment. 

Prognosis.  The  prognosis  is  always  guarded,  more  so  in  chil- 
dren than  in  adults.  It  is  usually  proportionate  to  the  severity  of 
the  symptoms.  Favorable  indications  are  moderate  fever,  only 
slightly  impaired  strength,  good  constitution,  and  moderate  exu- 
date, plus  early  and  vigorous  treatment. 

Unfavorable  signs  are  high  fever,  great  depression,  spreading 
exudate,  great  swelling  of  the  cervical  glands,  large  amounts  of 
albumin  in  the  urine,  extension  to  the  larynx  or  nasal  mucous 
membranes,  hemorrhages  from  the  fauces  and  nose,  and  the  gen- 
eral epidemic  character. 


DIPHTHERIA  499 

Death  results  from  involvement  of  the  larynx,  sudden  heart 
failure,  diphtheritic  paralysis,  septic  infection,  occasionally  from 
uremia,  or  broncho-pneumonia  during  convalescence. 

Prophylaxis.  Isolation  of  the  patient  should  be  absolute.  All 
bed  and  personal  linen  should  be  sterilized  by  boiling.  Instru- 
ments, tongue  depressors,  spoons,  etc.,  should  be  boiled  imme- 
diately after  use  or  kept  immersed  in  carbolic  acid  solution.  The 
room  after  the  patient  leaves  is  disinfected. 

Careful  scrutiny  of  milder  cases  of  sore  throat  during  epidemics 
will  assist  in  controlling  its  spread.  Strict  surveillance  during 
convalescence  is  also  necessary  for  the  same  purpose.  After  con- 
valescence is  established,  the  patient  should  be  washed  with  soap 
and  water,  then  with  50%  alcohol  (carbolic  acid  solution  2%,  or 
bichloride  of  mercury  1 :10,000)  for  three  successive  days.  The  hair 
should  be  similarly  treated  or  cut  off.  After  death  from  diphtheria, 
the  body  should  be  wrapped  in  a  sheet  which  has  been  soaked  in 
1 :3, 000  J  solution  of  bichloride  of  mercury  and  placed  in  a  closely 
sealed  coffin.    The  funeral  should  be  private. 

Quarantine.  The  period  of  quarantine  is  continued  until  two 
cultures  taken  on  different  days  are  negative. 


CHAPTER  XLVI 
DISEASES  DUE  TO  COCCUS  INFECTION 

LOBAR  PNEUMONIA 

(Lung  fever;  croupous  pneumonia  or  pneumonitis;  fibrinous  pneumonia;  specific 

pneumonitis) 

This  is  an  acute  infectious  disease,  variably  contagious,  due  to 
infection  by  the  micrococcus  lanceolatus,  and  characterized  chiefly 
by  pulmonary  symptoms  of  great  severity. 

Etiology.  The  specific  organism  is  almost  omnipresent  in  the 
mouth  and  in  dust.  It  grows  actively  only  when  the  tissue- 
resistance  is  lowered.  The  etiology  of  the  disease  is  practically 
the  etiology  of  lowered  immunity  in  general,  plus  some  factors  due 
to  the  peculiarity  of  the  organism.  While  atypical  pneumonias 
may  be  due  to  other  infectious  agents,  such  as  the  typhoid  bacillus, 
or  pyogenic  organisms,  these  usually  present  varying  symptoms 
referable  to  the  nature  of  the  invading  agent.  These  organisms 
gain  entrance  into  the  lung  tissue  through  respiration.  Since  they 
are  so  widely  distributed  in  persons  who  do  not  succumb  to  the 
infection,  it  is  evident  that  the  disease  cannot  be  considered  very 
contagious,  though  epidemics  sometimes  appear  to  be  due  to  organ- 
isms of  unusual  virulence,  and  in  these  an  increased  contagiousness 
often  appears. 

The  disease  is  most  frequent  in  the  late  winter  and  early  spring; 
it  may  or  may  not  appear  to  be  the  result  of  an  ordinary  "cold"  or 
influenza;  these  diseases  doubtless  lower  the  immunity  both  in 
general  and  in  specific  relation  to  pulmonary  infections.  It  very 
often  gives  death  to  the  senile  and  the  physically  defective ;  mental 
defectives  frequently  die  from  pneumonia  in  youth.  Heart  lesions, 
diabetes,  carcinoma,  nephritis,  anemia,  tuberculosis,  all  predispose 
to  pneumonia,  and  long  suffering  is  often  mercifully  prevented  by 
the  disease,  truly  named  "friend"  of  those  who  are  unfit  or  unable 
to  maintain  comfortable  existence  in  the  world. 

Bony  lesions  are  widespread,  as  is  to  be  expected  from  what 
has  been  said  of  other  etiological  factors.  Rigidity  of  the  mid- 
thoracic  region  is  the  most  frequent  finding  in  uncomplicated  cases. 
Other  lesions  include  those  of  the  cervical  region,  and  of  the 
ribs  and  clavicles.  Innominate  lesions  are  also  reported  as  caus- 
ative; this  is  probably  due  to  the  effects  produced  upon  upper 
spinal  relations  through  the  imbalance  caused  by  the  innominate 
lesions;  or  to  the  lowering  of  resistance  through  the  directly  irri- 
tating nervous  effects  of  the  lesion. 

500  *> 


PNEUMONIA  501 

Pathology.  The  structural  changes  follow  well-marked  stages,  and 
these  are  of  vital  importance  in  diagnosis,  treatment,  and  prognosis.  The 
first  stage  is  that  of  hyperemia,  followed  by  engorgement.  The  second  stage 
is  that  of  red  hepatization,  in  which  the  alveoli  are  filled  with  red  blood  cells. 
The  third  stage  of  gray  hepatization  is  due  to  the  partial  digestion  of  the  red 
blood  cells,  and  infiltration  of  the  mass  with  white  cells.  The  fourth  stage  is 
that  of  resolution,  in  which  the  blood  is  being  digested  and  absorbed,  and 
recovery  occurs.  The  treatment  and  symptoms  vary  during  these  stages,  and 
each  must  be  considered  independently. 

First  stage :  Hyperemia  and  engorgement.  The  onset  may  be 
very  acute;  in  elderly  or  poorly  nourished  persons  the  reaction 
may  be  less  pronounced.  The  changes  in  the  lung  begin  with 
acute  hyperemia,  due  to  the  presence  of  the  infectious  agent,  with 
the  other  etiological  factors  already  mentioned.  The  fever  rises, 
and  there  is  some  dyspnea.  The  hyperemia  increases;  the  lungs 
become  very  seriously  congested  and  a  few  white  cells,  followed 
by  many  red  cells,  begin  the  engorgement,  the  filling  of  the  alveoli 
with  blood  occurs  by  diapedesis;  few  or  no  rhexin  hemorrhages 
occur  in  typical  cases.  The  filling  of  the  alveoli  is  associated  with 
great  dyspnea  and  coughing.  During  the  first  few  hours  the  cough 
is  hard  and  dry,  perhaps  absent;  as  the  engorgement  and  the 
inflammation  progress  the  cough  becomes  looser,  often  with 
streaks  of  blood.  Intense  pain  is  associated  with  the  coughing, 
especially  if  the  pleura  is  involved. 

During  hyperemia  and  early  engorgement,  the  lung  sounds  are 
not  materially  changed.  Rales  may  be  heard,  variously,  according 
to  the  area  involved.  Percussion  notes  are  normal  or  slightly 
tympanic.  Dullness  may  begin,  and  progress  slightly  during  the 
later  stage  of  engorgement.  The  urine  is  of  the  ordinary  febrile 
type,  varying  according  to  height  of  the  fever.  The  blood  shows 
marked  and  early  leucocytosis;  slight  leucocytosis,  leucopenia,  or 
normal  counts  indicate  either  a  very  mildly  virulent  infection,  or 
very  diminished  resistance  on  the  part  of  the  patient.  The  poly- 
morphonuclear neutrophiles  are  unusually  high,  in  typical  cases. 
During  this  stage,  the  increase  is  in  the  younger  forms — the  finely 
granular  and  mononuclear  forms.  When  the  infection  is  severe  and 
the  resistance  low,  the  few  polymorphonuclears  show  ragged  out- 
lines, very  irregular  and  sometimes  extruded  nuclei,  atypical  forms 
and  granules,  and  many  masses  of  naked  nuclear  matter  are  found, 
all  indicating  the  effects  of  virulent  toxin  upon  blood  of  poor 
resisting  qualities.  The  systemic  blood  pressure  is  low,  in  early 
hyperemia,  increasing  during  the  increase  in  the  fever,  in  typical 
cases.  Suddenly  dropping  arterial  pressure  indicates  failing  heart, 
and  is  a  sign  of  great  danger  in  early  cases. 

The  treatment  during  this  time  must  include  thorough  and 
frequent  relaxation  of  the  interscapular  region  and  the  lower  tho- 
racic region ;  increased  mobility  of  the  entire  cervical  and  thoracic 
region;  if  possible,  correction  of  the  bony  lesions  as  found  on 


502  ^  DISEASES  DUE  TO  COCCI 

examination.  The  colon  usually  contains  an  increased  amount  of 
fecal  matter — this  must  be  removed,  preferably  by  enema  of 
warm  water,  carefully  given;  Any  of  the  usual  solutions  may  be 
employed,  provided  that  no  irritation  results.  The  patient  must 
be  placed  in  a  pleasant,  well-ventilated  room — the  ventilation 
is  the  most  important  thing.  The  windows  must  be  opened 
widely,  day  and  night,  unless  the  weather  is  unusually  inclement. 
Fresh  air  is  absolutely  the  most  important  thing,  after  the  struc- 
tural corrections,  in  the  treatment  of  pneumonia.  Warmth  may 
be  provided  by  blankets,  not  too  heavy,  hot  water  bottles,  irons, 
or  salt  bags.  The  thorax  may  be  wrapped  in  cotton  during  the 
stage  of  engorgement,  and  until  recovery ;  this  is  not  advised  in  all 
cases.  Usually  no  food  is  asked ;  none  but  liquids  should  be  given 
in  typical  cases.  These  may  include  hot  milk,  vegetable  broths, 
fruit  juices,  ice  cream,  according  to  the  season  and  the  patient's 
desires.  Plenty  of  cool  fresh  water  should  be  freely  given  during 
all  stages.  Steady  pressure  in  the  suboccipital  triangles,  or  at  the 
sides  of  the  ninth  to  the  eleventh  thoracic  spines,  lowers  the  blood 
pressure,  diminishes  the  cough,  and  lowers  the  temperature. 
Sponge  baths  of  water  at  body  temperature  lower  the  temperature 
and  give  much  relief.  Some  cases  can  be  aborted  during  this  stage, 
and  recovery  be  speedy. 

"In  all  pneumonia  cases  I  make  us.e  of  a  hygroscopic  clay  poultice  (such 
as  antiphlogistine)  from  the  very  start.  This  assists  greatly  in  relieving  con- 
gestion in  the  lungs  by  withdrawing  serum  through  the  skin  and  is  so  specific 
in  its  action  that  the  area-  of  inflammation  may  be  outlined  quite  precisely 
by  noting  the  semi-liquified  area  of  the  poultice.  These  poultices  should  be 
changed  at  least  every  twelve  hours.  Every  eight  hours  is  better  if  the 
physical  condition  of  the  patient  permits." — F.  A.  Cave. 

Stage  of  Hepatization.  Tiiis  includes  the  second  and  third 
stages,  of  red  and  of  gray  hepatization,  of  the  older  authors.  The 
blood  which  fills  the  alveoli,  during  the  stage  of  engorgement, 
coagulates.  If  the  lung  is  cut,  the  section  resembles  liver,  whence 
the  name.  A  piece  of  such  a  lung  sinks  readily  in  water.  Percus- 
sion elicits  a  dull  note  over  the  affected  area.  The  lung  sounds 
are  absent  over  this  lobe,  and  the  rest  of  the  lung  gives  rales  and 
sometimes  tympanic  nptes.  The  fever  is  very  high,  sometimes  to 
106°  F.,  delirium  may  be  present ;  the  cough  is  looser,  very  painful, 
and  productive  of  sputum,  usually  profuse,  and  of  a  rusty  appear- 
ance. The  color  is  due  to  the  partly  digested  blood,  with  its  hemo- 
globin transformed  partly  into  methemoglobin. 

Engorgement,  red  and  gray  hepatization  may  be  present  in 
different  parts  of  the  lung  at  the  same  time.  The  course  of 
events  is  not  materially  modified  by  this  fact.  When  the  lungs 
are  partly  filled  with  coagulated  blood,  the  clinical  picture  is  char- 
acteristic. The  blood  undergoes  autolysis,  becomes  partly  di- 
gested, and  the  white  cells  emigrate  into  the  affected  areas  in 


PNEUMONIA  .  503 

large  numbers.  These  changes  cause  the  hemoglobin  to  become 
somewhat  transformed  into  methemoglobin,  and  this  to  become 
further  broken  down  into  simpler  compounds.  These  changes, 
with  the  added  leucocytes,  give  the  grayish  appearance  referred 
to  as  gray  hepatization. 

The  urine  shows  the  febrile  changes  in  increased  degree;  the 
pulse  is  usually  quick  and  somewhat  irregular.  The  respiratory 
rate  is  very  high,  especially  in  relation  to  the  pulse — a  1 :2,  or  1 :1.5 
ratio  is  sometimes  seen  in  patients  who  recover.  The  blood  in 
strong  individuals  shows  marked  leucocytosis,  sometimes  to  25,000, 
with  a  high  neutrophile  percentage.  The  neutrophiles  present  a 
less  immature  appearance. 

During  this  stage  the  treatment  should  follow  the  outjine  pre- 
viously given  for  the  first  stage,  plus  efforts  to  maintain  the  oxygen 
intake.  When  the  condition  of  the  lung  is  recognized,  it  is  evident 
that  the  supply  of  fresh  air  must  be  kept  very  plentiful.  If  the 
respiratory  deficiency  is  considerable,  oxygen  may  be  given.  It 
may  be  necessary  to  use  an  inhalation  tube  at  first,  but  as  soon 
as  can  be  the  oxygen  should  be  allowed  to  escape  slowly  from  a 
pipe  near  the  patient's  nostrils.  The  oxygen  supply  should  be 
maintained  until  the  lungs  are  well  cleared  out.  During  the 
hepatization  the  heart's  action  is  labored,  and  the  heart  must  be 
kept  in  as  good  a  condition  as  possible  by  attention  to  the  condi- 
tion of  the  first  to  the  fourth  thoracic  segments.  The  ribs,  vertebrae, 
and  muscles  of  these  segments  must  be  watched,  and  all  lesions 
removed  speedily.  The  colon  must  be  kept  clean  by  enemas 
given  once  or  even  twice  a  day,  if  necessary.  The  ordinary  nurs- 
ing, with  reference  to  the  teeth,  etc.,  must  not  be  neglected.  The 
danger  of  hypostatic  congestion  must  be  remembered ;  the  patient 
who  is  weak  must  not  be  allowed  to  lie  too  long  a  time  in  any  one 
position,  but  must  be  moved  to  new  positions,  so  that  the  blood 
may  not  gravitate  constantly  into  the  same  areas.  During  this 
stage  treatments  should  be  given  once  to  three  or  four  times  each 
day.  It  is  often  necessary  to  remain  almost  constantly  within  call, 
for  hours,  if  the  patient  is  to  have  his  best  chance  of  recovery. 

Stage  of  Resolution.  The  termination  of  hepatization  should 
be  resolution.  The  coagulated  blood  undergoes  digestion,  partly 
as  the  result  of  autolysis,  partly  as  the  result  of  the  activity  of  the 
leucocytes,  partly  as  the  result  of  fatty  changes  going  on  in  the 
blood,  thus  freed  from  its  vessel  walls.  The  liquid  thus  produced 
varies  in  color,  from  variously  digested  pigments,  and  is  thin. 
Much  of  it  is  coughed  up,  by  the  loose  and  efficient  cough,  and 
some  of  it  is  absorbed  into  the  general  circulation  and  thus  carried 
away.  The  treatment  should  be  devoted  to  facilitating  resolution ; 
this  is  best  done  by  maintaining  a  constant  temperature  within 
the  thorax — this  is  the  place  for  the  cotton  wrappings  and  the 


.504  .  DISEASES  DUE  TO  COCCI 

antiphlogistin  and  the  various  wrappings  that  are  employed  for 
the  purpose  of  maintaining  a  constant  temperature  of  any  part 
of  the  body.  The  patient's  respirations  become  more  easy,  the 
loose  cough  diminishes,  and  he  seems  on  the  road  to  recovery. 
The  fever  drops  by  crisis,  often  below  normal,  sometimes  with 
fatal  collapse.  The  patient  is  left  very  weak,  but  the  delirium  and 
pain  disappear  with  almost  magical  celerity.  This  is  the  time 
during  which  cardiac  failure  is  a  serious  danger.  The  absorption 
of  the  resolved  liquid  may  allow  infection  of  distant  parts  of  the 
body;  the  meninges,  intestinal  tract,  and  any  of  the  mucous  or 
serous  membranes  may  become  the  seat  of  pneumococcus  infec- 
tions. 

The  .elimination  of  this  material  is  a  serious  matter.  The  kid- 
neys often  show  the  effects  in  a  nephritis  of  varying  severity.  The 
kidneys,  heart,  skeletal  muscles,  and  brain,  examined  during  death 
in  resolution,  show  fatty  metamorphosis  and  other  symptoms  of 
intense  toxemia.  All  these  organs  must  be  guarded  from  strain 
during  the  resolution,  absorption  and  elimination  of  the  lung 
detritus.  The  patient  must  remain  in  bed  until  every  sign  of  dan- 
ger has  passed,  and  he  must  not  try  to  engage  in  any  strenuous 
labor,  nor  any  intense  mental  effort,  for  several  weeks  after  the 
temperature  falls  to  normal. 

The  blood  shows  secondary  anemia,  and  there  are  many  ragged 
and  degenerated  and  senile  leucocytic  forms.  The  urine  is  that 
found  during  recovery  from  almost  any  fever.  The  pulse  increases 
in  strength  and  regularity,  and  the  appetite  increases.  It  is  often 
difficult  to  keep  a  patient  in. bed,  or  to  hold  him  to  a  rigorous 
diet,  as  long  as  is  safe,  for  he  rebels  against  confinement  when  he 
feels  so  well.  The  weakness  is  often  profound,  and  while  the 
sense  of  weakness  is  unpleasant,  it  yet  may  prevent  too  strenuous 
exertion  during  this  critical  period. 

Stage  of  Organization.  In  some  cases  the  resolution  does  not 
completely  occur.  The  coagulated  blood  undergoes  organization, 
the  migrating  cells  and  the  leucocytes,  with  perhaps  other  cellular 
elements,  form  masses  of  rather  dense  connective  tissue,  which  fill 
the  alveoli.  This  condition  is  not  usually  immediately  fatal  but  it 
lessens  the  usable  lung  space,  and  is  apt  to  become  the  seat  of 
later  infectious  processes. 

Complications.  Headache  is  present  with  the  fever.  Alcoholic 
patients  are  prone  to  delirium,  at  the  onset  of  pneumonia.  The 
pneumococcus  may  invade  the  meninges,  whereupon  the  symp- 
toms of  cerebrospinal  meningitis  are  produced.  When  the  infec- 
tion is  limited  to  the  cerebral  meninges,  the  diagnosis  may  be  very 
difficult.  The  toxins  of  the  disease  may  cause  somnolence,  delir- 
ium, and  other  nervous  symptoms,  without  meningeal  infection. 


PNEUMONIA  505 

Especially  in  the  weak,  very  young^  or  senile,  the  disease  is  apt  to 
be  associated  with  low  delirium — with  no  meningeal  involvement. 
Cerebral  symptoms  are  avoided  by  preventing  undue  excite- 
ment and  by  keeping  the  cervical  muscles  and  other  tissues  in 
normal  condition. 

Pleurisy  is  to  be  expected.  When  the  pleuritic  involvement  is 
marked  the  respiratory  pain  is  more  severe ;  coughing  also  is  very 
painful.  When  the  pleuritic  symptoms  are  conspicuous,  the  disease 
is  called  pleuro-pneumonia.  Effusion  often  occurs,  and  may  be 
overlooked  in  the  severity  of  the  lung  symptoms.  The  fluid  is 
richer  in  fibrin  than  is  the  more  frequent  pleurisy  with  effusion. 
Invasion  by  the  pyogenic  bacteria  may  result  in  empyema.  These 
conditions  are  avoided,  in  most  cases,  by  the  treatment  outlined 
for  the  pneumonia. 

Pericarditis  and  endocarditis  are  frequent  complications  and 
sequelae.  These  are  avoided  by  keeping  the  patient  very  quiet 
from  the  beginning  of  the  disease,  and  by  preventing  too  hasty 
return  to  the  upright  position  and  to  the  ordinary  duties  of  life. 
Lesions  of  the  upper  thoracic  region  should  be  prevented  or  cor- 
rected. Thrombosis  may  occur,  and  lead  to  sudden  death,  or  tq 
cerebral  involvement.  It  is  not  possible  to  guard  against  this 
complication,  except  as  the  maintenance  of  good  circulation  may 
prevent  abnormal  blood  states,  and  the  usual  treatment  for  the 
disease  may  facilitate  recovery. 

Rarely,  nephritis,  neuritis,  parotitis,  arthritis,  gastritis,  colitis 
or  hepatitis  may  result  from  the  invasion  of  the  organs  mentioned 
by  the  pneumococcus.  The  treatment  as  above  outlined  provides 
the  necessary  protection ;  plus  the  usual  hygienic  care  of  the  body 
as  a  whole. 

"A  specific  treatment,  directed  toward  the  relaxation  of  the  tightened 
muscles  about  the  chest  and  the  dorsal  spine  and  toward  the  raising  of  the 
ribs,  can  be  given  with  profit  every  four  hours  during  the  first  twenty-four  or 
possibly  forty-eight  hours,  according  to  the  conditions,  and  as  frequently  there- 
after as  conditions  demand." — C.  A.  Williams. 

"The  important  symptoms  to  be  controlled  are  the  dyspnea,  cough,  pain, 
tympanites,  fever,  toxemia,  and  weakened  heart  action. 

"The  dyspnea  may  be  controlled  by  elevation  of  the  ribs  and  by  draining 
the  congested  lung  to  some  other  part.  This  may  be  accompanied  by  pressure 
in  the  lower  dorsal,  dilating  the  abdominal  vessels,  or  by  hot  abdominal  packs, 
or  hot  leg  packs  to  dilate  the  surface  blood  vessels  of  lower  extremity.  The 
cough  may  be  controlled  by  the  above  measures,  and  in  addition  work  on 
clavicles  and  first  and  second  ribs  and  at  the  fourth  dorsal.  The  pain  is  con- 
trolled by  separation  of  the  ribs,  relieving  the  pleura  of  pressure  and  securing 
efficient  lymphatic  drainage  of  the  affected  area  by  separation  of  the  ribs  and 
relaxation  of  the  axillary  structures.     ... 

"Treatment  should  be  given  frequently,  once  in  six  or  eight  hours  at 
least.  .  .  .  Manipulations  should  be  given  by  slow  movements  across  the 
muscles,  using  strong  pressure  throughout  the  dorsal  region  and  cervical  area 
to  thoroughly  relax  the  musculature  and  interosseous  structures.    .    .    .    Dr. 


506  DISEASES  DUB  TO  COCCI 

Whiting  showed  us  that  treatment  in  the  lower  dorsal  and  to  the  Hver  and 
spleen  will  increase  the  opsonic  index  for  a  period  of  from  six  to  eight  hours." 
~G.  V.  Webster. 

"In  case  of  extreme  delayed  resolution,  particular  attention  should  be  given 
the  region  of  the  fourth  dorsal  vertebra,  as  treatment  at  this  point  will  assist 
in  strengthening  the  heart,  which  has  to  work  against  heavy  pressure  in  these 
cases.  All  cervical  lesions  should  be  carefully  searched  out  and  corrected, 
and  the  neck  muscles  kept  in  a  state  of  relaxation  throughout  the  course  of  the 
disease." — J.  A.  Overton. 

The  labored  breathing  in  pneumonia  can  be  relieved  to  some 
extent  by  careful  and  gentle  dilatation  of  the  nostrils.  For  this 
purpose  an  ordinary  wire  dilator  may  be  used. 

Prognosis.  Recovery  is  to  be  expected  in  adults,  who  receive 
proper  attention  early.  Cases  aborted  during  the  first  stage  are 
hardly  to  be  diagnosed ;  thus  it  is  not  possible  to  know  how  many 
such  cases  are  to  be  found.  If  treatment  is  delayed  until  after 
the  symptoms  of  hepatization,  recovery  can  only  be  expected  after 
resolution — the  coagulated  blood  cannot  be  absorbed  until  after 
it  has  been  digested  and  made  fluid.  The  prognosis  is  much 
more  serious  in  elderly  patients,  in  the  very  young,  and  in  persons 
who  are  weakened  from  other  diseases.  Pneumonia  is  a  good 
friend  of  the  aged,  the  defective,  and  the  insane — many  deaths 
occur  in  these  unfortunates,  no  matter  how  well  cared  for.  It 
terminates,  not  too  painfully,  many  unhappy  and  useless  lives. 

EPIDEMIC  CEREBROSPINAL  MENINGITIS 

(Brain  fever;  cerebrospinal   fever;  spotted   fever;   epidemic   spinal  fever; 
malignant  purpuric  fever) 

This  is  an  acute  infectious  disease,  characterized  by  irregular 
course,  moderate  fever,  and  profound  nervous  symptoms;  it  is  due 
to  the  diplococcus  intracellularis  meningitidis.  It  may  be  sporadic, 
epidemic,  or  pandemic. 

Pathology.  The  disease  is  essentially  an  acute  inflammation  of  the 
pia-arachnoid ;  the  dura  is  involved  later.  Almost  every  organ  in  the  body 
shows  the  effect  of  the  invading  bacteria — pericarditis,  sometimes  endocarditis 
and  myocarditis  show  the  cardiac  effects ;  kidneys  and  liver  show  granular  and 
sometimes  fatty  degeneration ;  spleen  and  liver  are  enlarged  and  full  of  blood ; 
lungs  show  bronchitis  and  pneumonitis ;  skeletal  muscles  show  granular  degen- 
eration ;  nerve  trunks  show  neuritic  changes ;  the  brain  and  the  cord  are 
variously  injured.  Meningeal  spaces  and  ventricles  are  filled  with  a  fluid,  first 
only  increased  in  quantity,  later  containing  white,  then  red  blood  cells,  and 
bacteria;  still  later  the  fluid  is  purulent  and  of  greenish  yellow  color. 

After  recovery,  adhesions  between  the  thickened  pia-arachnoid  and  the 
dura,  or  the  cord  and  the  brain,  are  frequently  found ;  these  adhesions  may 
be  responsible  for  many  symptoms  occurring  for  months,  sometimes  for  years, 
after  recovery  from  the  acute  disease. 

Etiology.  The  diplococcus  meningitidis  is  the  infectious  agent. 
It  resembles  the  pneumococcus  in  many  respects,  and  the  gono- 
coccus  in  other  qualities.    It  is  biscuit  shaped,  and  is  found  within 


EPIDEMIC  MENINGITIS  507 

the  leucocyte  protoplasm,  but  not  within  the  nucleus.  It  is  recov- 
ered from  the  cerebrospinal  fluid,  the  nasal  secretions  especially,  the 
pus,  the  urine,  and  probably  other  secretions.  With  this  organism 
other  bacteria  are  usually  associated — the  pneumococcus,  bacillus 
coli  communis,  and  various  pyogenic  organisms. 

Bony  lesions  of  the  cervical  and  upper  thoracic  region  appear 
to  predispose  to  the  disease.  Lesions  of  the  upper  ribs  are  re- 
ported. Occiput,  atlas  and  axis  lesions  are  present  in  some  cases; 
these  lesions  have  been  found  in  a  few  patients  who  afterward 
became  infected.  Various  bony  lesions  result  from  the  inflamT 
matory  process,  and  these  may  perpetuate  certain  symptoms  for 
months  after  the  acute  attack  has  passed. 

Children  and  young  adults  are  most  frequently  affected.  The 
disease  is  almost  unknown  in  warm  climates ;  it  is  most  prevalent 
in  the  Northern  areas  of  the  temperate  zone.  Unhygienic  sur- 
roundings predispose;  crowding,  as  in  the  slums  and  in  barracks, 
prisons,  and  orphan  asylums  encourages  the  spread  of  the  disease. 

The  infectious  bacteria  may  be  carried  from  one  person  to 
another  by  means  of  the  nasal  or  other  secretions ;  these  may 
retain  their  virulence  for  some  hours;  possibly  for  some  days  or 
weeks.  Fomites  may  be  responsible  for  the  spread ;  older  adults 
are  often  "carriers"  and  may  spread  the  disease  through  uncleanli- 
ness  in  regard  especially  to  nasal  secretions. 

The  mode  of  entrance  into  the  body  is  not  known.  Breathing 
infected  dust  may  permit  the  infection  of  the  nasal  passages, 
whence  the  blood  and  lymph  carry  the  bacteria  over  the  body. 
Direct  extension  by  way  of  the  nasal  lymphatics  and  the  olfactory 
nerves  is  not  improbable. 

Diagnosis.  This  is  based  upon  the  symptoms,  especially  in  an 
epidemic,  and  upon  the  recognition  of  the  specific  bacteria  in  the 
nasal  secretions  and  the  cerebrospinal  fluid. 

The  incubation  period  is  unknown,  though  brief;  probably 
three  to  ten  days.  Prodromal  symptoms  vary ;  the  onset  may  be 
frightfully  sudden,  or  there  may  be  a  few  days  of  lassitude,  back- 
ache, headache,  and  slight  feverishness.  Nausea  and  vomiting 
may  occur  as  prodromal  symptoms.  Most  cases  have  rather  sudden 
onset  in  the  afternoon  or  early  night.  Fever  is  moderate ;  headache 
and  backache  are  extreme ;  children  may  have  convulsions ;  retrac- 
tion of  the  head,  opisthotonos  and  spinal  rigidity  are  marked. 
Vomiting  may  be  serious;  sometimes  projectile.  During  the  first 
few  days  the  fever  varies,  rarely  going  above  103°  after  the  first 
day.  In  rapidly  fatal  cases,  the  temperature  may  reach  remarkable 
heights — 110°  or  more,  at  death.  The  pulse  is  accelerated  practi- 
cally with  the  fever.  Hyperpnea  and  Cheyne-Stokes  breathing  may 
occur;  respirations  may  be  slowed  by  pressure  upon  the  bulbar 
center;  death  may  occur  from  this. 


508  DISEASES  DUE  TO  COCCI 

Hyperesthesia  is  marked;  the  slightest  sensory  stimulation  of 
any  kind  is  intensely  painful,  and  increases  the  muscular  rigidity. 
Coma  and  delirium  may  appear  early;  they  are  rarely  absent  in 
mild  cases.  Especially  toward  night  there  is  a  tendency  for  the 
delirium  to  become  hysterical  in  females,  and  maudlin  or  sentimen- 
tal in  males ;  eroticism  may  be  noticed ;  priapism  and  emissions  are 
not  rare  in  males.  Muscular  twitchings,  spasms,  and  choreic  move- 
ments may  occur;  paralysis  is  rare.  Herpes  is  common.  A  pete- 
chial, purpuric,  or  urticarial  eruption  is  frequent;  whence  the 
name  "spotted  fever."  In  severe  cases  the  skin  eruptions,  bed- 
sores, and  ecchymoses  may  terminate  in  gangrene. 

The  blood  shows  moderate  leucocytosis ;  water  is  usually  defi- 
cient. The  urine  shows  ordinary  changes  of  acute  fevers;  occa- 
sionally the  nephritis  may  be  serious.  Reflexes  are  increased; 
Kernig's  sign  is  usually  present  but  is  not  in  itself  pathognomonic. 

Rudimentary  types  are  very  mild ;  the  diagnosis  would  probably 
not  be  made  except  during  an  epidemic. 

Abortive  forms  begin  with  marked  symptoms,  which  speedily 
disappear;  recovery  is  rapid,  and  the  entire  disease  persists  only 
for  a  week  or  so. 

Intermittent  forms  are  characterized  by  remarkably  rapid  im- 
provement at  intervals  for  two  or  three  days ;  these  are  followed 
by  equally  rapid  exacerbations  within  a  few  hours  or  a  day. 

Typhoid  forms  are  characterized  by  a  steady,  slow  course,  with 
stupor  and  coma,  and  extremely  slow  recovery  or  delayed  death. 

Fulminant  type;  apoplectic  type,  begins  very  suddenly,  runs  a 
rapid  course  with  death,  sometimes  within  a  few  hours.  When 
death  is  delayed  for  a  few  days,  the  eruption  is  purpuric  and  in- 
volves the  mucous  membranes  and  the  meninges.  All  symptoms 
are  extremely  intense ;  the  pulse  is  usually  slow  and  feeble. 

Complications.  The  eyes  are  often  inflamed.  Conjunctivitis, 
iritis,  retinitis,  panophthalmitis,  optic  neuritis,  may  result  in  blind- 
ness after  recovery  from  the  acute  disease.  Inflammation  of  the 
internal  and  middle  ear  is  not  infrequent,  and  partial  or  complete 
deafness  may  result.  Involvement  of  the  nerves  at  the  base  of  the 
brain  may  cause  permanent  facial  paralysis,  usually  with  hemi- 
atrophy. Infection  of  the  lungs  with  the  ever-present  pneumo- 
coccus  or  tubercle  bacillus  may  hasten  death.  Pneumonia  is  usually 
speedily  fatal.  Infection  of  the  pericardium,  myocardium,  and 
endocardium  are  frequent;  sudden  death  may  be  due  to  these 
inflammations,  or  the  heart  may  be  left  injured  after  recovery 
from  the  acute  disease.  The  liver  and  spleen  are  always  involved, 
but  these  usually  recover  with  the  disappearance  of  the  acute  symp- 
toms.    The  kidneys  are  seriously  infected,  and  may  be  left  with 


EPIDEMIC  MENINGITIS  509 

varying  degrees  of  parenchymatous  nephritis;  death  may  occur 
from  this,  months  after  the  symptoms  of  meningitis  have  dis- 
appeared. 

The  brain  and  cord  are  often  associated  in  the  inflammatory 
process.  Permanent  paralysis  of  certain  muscle  groups  is  not 
infrequent.  Cerebral  injury  may  leave  the  patient  with  mental 
defect ;  in  a  child,  this  may  cause  idiocy,  imbecility,  or  feeble-mind- 
edness,  or  may  merely  diminish  slightly  his  capabilities  in  mental 
development ;  in  adults  dementia,  chronic  confusional  insanity,  or 
merely  an  emotional  instability  may  persist.  Confusional  states 
and  memory  defects  may  persist  for  a  time,  and  then  pass  away. 

Treatment.  The  sick  room  must  be  clean,  well  aired,  quiet 
and  dimly  lighted.  Only  the  nurse  should  be  permitted  within  the 
room,  and  all  noise  and  confusion  carefully  avoided.  The  pain 
that  is  caused  by  the  least  noise,  or  by  being  compelled  to  move 
or  to  talk,  or  by  moving  objects  or  lights,  is  beyond  imagination. 
During  the  high  fever,  fruit  juices  alone  are  permitted;  much 
water  is  given ;  the  patient  is  not  to  be  disturbed  except  at  long 
intervals  for  water.  The  lips  may  be  kept  moist  by  a  cotton  pad 
in  ice  water,  a  small  amount  of  this  water  may  be  swallowed, 
when  the  patient  is  too  sick  to  drink.  This  constant  washing  of 
the  lips  is  pleasant  and  grateful ;  it  may  prevent  labial  herpes. 
With  subsidence  of  the  fever,  liquid  foods,  milk,  vegetable  juices 
and  broths  may  be  given  in  greatly  diluted  form  and  at  diminish- 
ing intervals.  Convalescence  may  be  shortened  by  providing 
nutritive  food  as  soon  as  it  can  be  digested  and  absorbed.  A  bent 
glass  tube  should  be  used;  the  patient  should  not  be  compelled  to 
make  any  exertion.  It  is  essential  that  a  good  nurse  be  provided; 
proper  feeding,  changing,  bathing,  and  attention  to  the  bedding, 
and  to  the  bowels  and  bladder  of  the  patient  can  only  be  secured 
through  the  care  of  a  well-trained  nurse.  This  skillful  care  may 
mean  life  instead  of  death ;  certainly  it  means  a  more  speedy  recov- 
ery, with  less  of  suffering  during  the  attack. 

The  patient  should  not  be  permitted  to  remain  upon  his  back; 
the  lateral  or  the  prone  position  is  much  better.  The  weight  of 
the  body  upon  the  back  increases  opisthotonos ;  the  influence  of 
gravity  increases  the  meningeal  congestion,  when  the  patient  lies 
supine;  and  this  position  encourages  heat  retention  in  the  spinal 
tissues.  The  lateral  positions  are  far  better  in  every  respect; 
though  the  patient  has  a  strong  tendency  at  all  times  to  assume 
the  supine  position. 

From  the  beginning  of  the  disease  until  convalescence  is  well 
established,  a  very  gentle  general  spinal  treatment  should  be  given 
once  or  twice  each  day.  If  the  symptoms  recur,  this  treatment 
may  be  repeated  at  intervals  of  a  few  hours ;  otherwise,  the  visits 
may  be  postponed  for  a  day;  later,  the  intervals  are  increased; 


510  DISEASES  DUE  TO  COCCI 

but  it  is  much  better  to  risk  an  extra  visit  than  to  allow  too  long 
an  interval  to  elapse. 

Ice  bags  are  of  great  value.  An  ice  cap  to  the  head  gives  great 
relief;  ice  bags  to  the  neck  often  reduce  the  retraction  of  the  head 
and  give  sleep;  long,  slender  bags  to  the  spinal  region  relax  mus- 
cles and  lessen  hyperesthesia.  A  hot  water  bottle  may  be  placed 
at  the  feet  or,  rarely,  over  the  abdomen,  if  there  is  a  tendency 
toward  too  great  chilling. 

Prognosis.  The  prognosis  must  be  guarded  in  all  cases,  espe- 
cially with  reference  to  sequelae.  Not  for  weeks  after  apparent 
recovery  may  one  be  sure  ill  eflfects  are  not  left  by  the  inflamma- 
tion. Recovery  is  usually  to  be  expected,  except  in  the  apoplectic 
or  fulminant  types;  there  is  much  variation  in  the  virulence  in 
different  epidemics,  therefore  in  certain  types  everything  depends 
upon  early,  vigorous  and  constant  attention.  It  would  seem  that 
Flexner  serum  is  of  value  in  the  severe  types,  in  comparison  with 
previous  medical  methods.  The  sequelae  have  already  been  men- 
tioned under  the  head  of  "complications." 

INFANTILE  PARALYSIS 

(Acute  anterior  poliomyelitis) 

This  is  an  acute  infectious  disease  of  the  spinal  cord,  charac- 
terized by  sudden  onset  with  high  fever,  and  complete  paralysis 
of  one  or  more  limbs  or  muscle  groups,  followed  by  rapid  atrophy 
of  the  paralyzed  limbs.  Pain  may  be  present  at  the  onset  of  the 
disease,  but  there  are  no  permanent  sensory  disturbances. 

Etiology.  The  disease  is  due  to  a  streptococcus  (Rosenow)  or 
micrococcus  (Nuzum)  of  peculiar  variability.  Grown  without  oxy- 
gen it  is  filterable ;  grown  aerobically,  it  attains  greater  size  and 
wider  virulence.  It  can  be  cultured  from  tonsils  and  nasal  and  other 
secretions,  and  the  culture  produces  the  disease  in  several  lower 
mammals,  from  whom  identical  or  variable  cultures  can  again.be 
secured.  The  manner  of  transmission  has  not  yet  been  determined. 
Flexner's  experiments  show  that  it  is  quickly  destroyed  by  the 
blood,  though  it  lives  for  some  time  in  the  lymph  or  mucous  secre- 
tions. The  point  of  entry  is  probably  by  the  nasal  passage  and 
upward  through  the  cribriform  plate  by  way  of  the  lymph  spaces 
surrounding  the  nerves  and  blood  vessels  passing  into  the  nasal 
cavity.  Most  animals  are  subject  to  this  infection  though  they  do 
not  all  show  typical  paralytic  symptoms  and  in  them  it  frequently 
runs  a  much  more  chronic  course.  It  is  probable  that  pet  dogs 
or  cats  who  carry  this  disease  in  its  chronic  form  may  be  respon- 
sible for  the  appearance  of  sporadic  cases  in  children  or  may  even 
initiate  serious  epidemics.  One  attack  gives  immunity.  There 
are  few  exceptions  to  this  statement. 


INFANTILE  PARALYSIS.  511 

Other  infectious  agents  such  as  those  of  diphtheria,  measles, 
pneumonia,  scarlet  fever,  malaria  and  furunculosis  may  gain 
entrance  to  the  anterior  gray  matter  of  the  spinal  cord  and  give 
rise  to  symptoms  not  to  be  distinguished  from  those  due  to  the 
epidemic  form  of  infantile  paralysis. 

Exposure  to  cold  and  sudden  check  of  perspiration,  wading  in 
cold  water,  or  some  trauma,  such  as  a  blow  or  fall  or  jar  are 
often  given  as  causes  of  the  disease  by  parents.  These  factors  may 
easily  be  contributing  causes  by  lowering  the  resistance  of  the 
body  to  infection.  Experimental  work  done  upon  animals  by 
C.  P.  McConnell '  and  others  shows  that  such  factors  as  those 
already  mentioned  may  interfere  with  the  circulation  through 
localized  areas  of  the  spinal  cord.  Thus  it  is  very  probable  that 
trauma,  temperature  variations,  etc.,  may  act  as  predisposing  fac- 
tors not  only  in  a  general  but  also  in  a  rather  strictly  localized  way. 

The  disease  is  very  much  more  frequent  during  the  summer 
months  and  especially  in  dry  weather  when  the  germ-laden  dust 
is  more  plentifully  inhaled  and  flies  are  plentiful.  Both  sexes 
are  afflicted  in  about  the  same  way. 

The  favorite  age  is  from  one  to  four  years.  Children  are  said 
to  have  been  born  with  the  paralysis  though  it  is  not  certainly 
known  that  intra-uterine  infection  really  exists.  The  difficulty 
in  making  the  differential  diagnosis  between  this  and  other  causes 
of  congenital  paralysis  is  easily  seen.  The  earliest  typical  case 
on  record  is  that  of  an  infant  four  days  old.  It  rarely  occurs 
above  ten  years  of  age  though  it  has  been  known  to  affect  men 
and  women  up  to  thirty  or  more  years.     (See  Landry's  paralysis.) 

Pathology,  The  effects  of  the  disease  are  marked  in  the  anterior  gray 
matter  of  the  spinal  cord.  During  the  acute  stage  profound  inflammatory 
changes  are  found  in  the  gray  matter.  These  are  followed  by  degeneration  and 
atrophy  of  a  large  number  of  nerve  cells  including  all  of  the  large  multipolar 
cells  in  the  affected  areas.  The  nerve  fibers  degenerate  and  disappear  and  the 
muscles  undergo  very  rapid  atrophy.  The  bones  and  the  joints  normally  moved 
by  these  muscles  also  cease  growing  to  a  very  marked  extent.  Contraction  of 
the  tendons  of  the  paralyzed  muscles  together  with  the  wasting  of  the  joint 
tissues  brings  about  various  deformities. 

Symptoms,  Like  other  acute  infections  this  disease  begins 
with  fever,  which  goes  up  to  about  103°,  rarely  105°.  This  may 
begin  with  a  chill  and  may  be  associated  with  profound  perspira- 
tion. The  temperature  usually  returns  to  101°  or  102°  within  a 
few  hours  or  a  day  and  remains  at  that  point  for  several  days. 
Vomiting,  rigidity  of  the  neck  muscles,  and  pain  on  movement  are 
characteristic  symptoms.  There  is  not  usually  more  than  a  week 
after  the  onset  imtil  the  fever  has  completely  disappeared.  Death 
may  occur  during  the  first  and  marked  hyperpyrexia.  Opisth- 
otonos may  suggest  meningitis.  Delirium  and  convulsions  may 
occur.  In  about  90%  of  the  cases  digestive  disturbances,  nausea, 
vomiting,  and  diarrhea  are  present.     Sometimes  the  fever  is  not 


512  DISEASES  DUE  TO  COCCI 

marked,  digestive  symptoms  are  absent  and  there  is  only  a  few 
hours  or  perhaps  a  few  days  of  slight  malaise.  The  t-hermometer 
would  probably  always  show  some  rise  of  temperature  in  such 
cases  but  this  apparently  mild  attack  very  frequently  evades  notice. 

The  paralysis  is  first  noticed  on  the  first  to  fifth  days.  At  first 
it  includes  a  very  widespread  area.  There  may  be  great  pain  in 
the  joints  and  muscles  when  motion  is  contemplated.  The  skin, 
muscles  and  bones  are  frequently  hypersensitive  to  pressure.  With 
the  passing  of  the  fever  the  sensory  symptoms  abate.  The  extent 
of  the  paralysis  diminishes  rapidly  for  a  few  weeks;  more  slowly 
for  a  few  months.  At  about  three  or  four  months  after  the  acute 
attack  the  true  extent  of  the  paralysis  is  usually  evident.  At 
first  the  paralyzed  limbs  are  cold,  mottled  and  edematous.  In  the 
cases  in  which  the  fever  is  not  noticeable  the  paralysis  seems  to 
occur  very  suddenly  with  no  prodromal  symptoms  whatever. 

The  right  leg  is  somewhat  more  often  affected  than  the  left. 
Both  legs  are  affected  rather  less  frequently  than  either  alone. 
If  both  an  arm  and  leg  are  affected  they  are  usually  upon  the  same 
side  of  the  body.  Rarely  the  muscles  of  the  back  are  involved; 
this  may  produce  a  lordosis  or  scoliosis.  Sometimes  the  disease 
affects  the  medullary  motor  centers.  The  third,  fourth,  sixth, 
seventh,  and  twelfth  nerves  may  be  paralyzed.  Torticollis  may 
result  when  the  eleventh  nerve  is  involved.  When  the  visceral 
centers  in  the  medulla  are  affected  death  results  at  once. 

Hypertrophy  of  the  opposing  muscles  or  of  the  nonparalyzed 
limbs  may  be  very  marked.  The  arms  may  become  so  strong  and 
large  as  to  suggest  partly  replacing  in  function  the  paralyzed  legs. 
Remarkable  accounts  of  hypertrophy  of  the  tongue  and  its  assump- 
tion of  very  complex  functions  are  recorded  in  cases  in  which  the 
paralysis  involves  both  legs  and  both  arms. 

Diagnosis  during  the  acute  stage  may  be  difficult.  The  sudden 
onset,  with  gastro-intestinal  symptoms  for  which  none  of  the  usual 
causes  can  be  found,  rigidity  of  the  posterior  neck  muscles,  some- 
times of  other  spinal  muscles,  and  evidences  of  pain  upon  move- 
ment, should  indicate  the  diagnosis,  which  is  only  to  be  considered 
definitely  established  with  the  onset  of  paralysis.  After  the  acute 
stage  has  subsided,  the  history  of  sudden  onset  with  no  anes- 
thesia and  no  bladder  symptoms,  the  atrophy  of  muscles  and  bones, 
the  lack  of  reflexes  and  the  reaction  of  degeneration  in  the  affected 
muscles  should  make  the  diagnosis  easily  evident.  Every  case  of 
sickness  in  children  should  be  viewed  with  suspicion  during  an 
epidemic,  but  it  is  not  possible  to  make  the  diagnosis  until  the 
occurrence  of  localized  hyperesthesia  or  paralysis. 

Acute  transverse  myelitis  rarely  affects  children  and  in  this 
disease  the  bladder  and  rectum  are  involved  and  bedsores  appear 
very  speedily. 


INFANTILE  PARALYSIS  513 

Multiple  peripheral  neuritis  is  rare  in  children.  There  are  grad- 
ual onset,  and  more  severe  pain ;  the  muscles  and  nerve  trunks  are 
very  sensitive  to  pressure,  and  there  is  a  history  of  alcoholism  or 
some  other  cause  of  the  neuritis. 

Spinal  hemorrhage  has  more  marked  sensory  symptoms.  Pain 
and  temperature-sense  are  lost  speedily.  The  bladder  and  rectum 
are  usually  paralyzed  and  some  muscle  groups  are  not  affected. 
Progressive  muscular  atrophy  has  a  gradual  onset  and  the  par- 
alyzed area  increases  constantly  in  extent. 

Spastic  hemiplegia  due  to  cerebral  lesions  is  characterized  by 
rigidity  of  the  limbs ;  increased  reflexes,  no  reaction  of  degenera- 
tion and  atrophy  is  either  not  present  or  else  is  very  diffuse.  Erb's 
paralysis  involves  the  deltoid,  biceps,  brachialis  anticus  and  supi- 
nator longus,  rarely  other  muscles,  and  is  due  to  birth  injury; 
diminished  cutaneous  sensation  is  usually  present  over  area  sup- 
plied by  the  fifth  and  sixth  cervical  nerves.  This  location  and  the 
history  of  birth  trauma  should  make  diagnosis  easy. 

Treatment.  During  an  epidemic,  all  children  of  susceptible  age 
should  be  examined,  and  all  bony  and  other  lesions  corrected. 
Food  and  other  conditions  of  hygiene  should  be  investigated. 
These  factors  are  important  in  preventing  the  disease,  and  in 
increasing  the  resistance  of  the  body  to  the  disease. 

Every  sick  child  should  be  isolated;  every  child  with  feven 
should  be  put  to  bed  in  a  quiet  room,  protected  from  insects. 
During  the  fever,  plenty  of  cool  water  should  be  given,  and  per- 
haps some  of  the  fruit  juices;  nothing  more  of  food.  Usually  an 
enema  is  needed  the  first  day;  sometimes  for  several  days.  The 
fever  can  be  controlled  by  sponging  with  water  at  the  skin  tem- 
perature. These  things  must  be  done  with  great  care,  to  avoid 
painful  movement. 

It  is  most  important  that  the  child  should  not  be  allowed  to 
lie  upon  the  back.  The  left  or  right  lateral  position  is  usually 
comfortable  and  is  very  good.  No  weight  of  bed  clothes  should 
be  permitted  upon  the  body;  a  frame  is  easily  arranged  for  their 
support.    Movements  are  painful,  and  rest  is  greatly  to  be  desired. 

The  osteopathic  treatment  includes  also  the  relief  of  the  mus- 
cular rigidity.  Extension  of  the  neck  and  the  spinal  column  gen- 
erally and  very  gentle  movements  for  the  relief  of  the  spinal 
rigidity  are  usually  attended  with  relief  of  the  pain  and  this 
should  be  given  two  or  three  times  each  day  during  the  acute  stage 
of  the  disease.  As  the  fever  subsides,  the  extent  of  the  paralysis 
becomes  evident.  As  soon  as  manipulations  are  not  painful,  mas- 
sage of  the  affected  limbs,  following  the  course  of  the  nerve  trunks 
to  and  including  the  muscles,  is  helpful.  This  is  not  to  be  done 
when  any  pain  is  produced.  The  diet  should  return  to  the  normal 
gradually,  after  the  fever  disappears. 


514  DISEASES  DUE  TO  COCCI 

I 

Even  after  the  paralysis  is  complete,  much  help  can  be  given 
by  osteopathic  treatment.  There  is  good  reason  to  believe  that 
a  better  circulation  through  the  spinal  cord  promotes  the  recovery 
of  cells  which  have  been  injured  but  not  destroyed  by  the  infection 
and  also  promotes  the  assumption  of  increased  duties  by  nerve 
cells  of  an  immature  type.  The  massage  and  stretching  of  the 
injured  muscles  gives  some  good  results  in  the  earlier  weeks.  It 
is  of  less  value  after  the  third  or  fourth  month. 

Violent  stretching  of  the  muscles  and  tendons  under  anesthesia 
is  sometimes  followed  by  the  correction  of  deformities  of  the  limbs, 
though  a  dangerous  operation  unless  skillfully  done.  Tenotomy 
and  myotomy  are  performed  for  the  sake  of  lengthening  the  con- 
tractured  tendons  and  muscles.  Arthrodesis  is  sometimes  per- 
formed for  the  sake  of  giving  fixation  in  those  joints  left  abnor- 
mally flexible. 

Tendon  transplantation  is  the  shifting  of  the  tendon  of  one  of 
the  normal  muscles  on  to  the  paralyzed  side  of  the  bone.  In  this 
way  a  fairly  good  amount  of  control  is  frequently  secured.  Neuro- 
plasty  is  performed  in  two  ways.  Sometimes  a  healthy  nerve  is 
split  and  one  end  is  sewed  into  the  paralyzed  muscle.  Or,  the  par- 
alyzed nerve  trunk,  when  it  can  be  found,  is  sometimes  set  into  a 
healthy  nerve.  In  either  case  nerve  filaments  grow  into  the  par- 
alyzed muscle  by  the  slow  process  of  regeneration  and  ultimately 
the  muscle  returns  to  something  of  its  normal  tone.  The  nerve 
centers  in  the  central  nervous  system  must  be  reeducated  in  such 
a  case  in  order  that  volitional  control  may  be  secured.  The 
osteopathic  treatment  of  patients  for  whom  any  of  these  orthopedic 
measures  are  being  employed  should  never  be  forgotten.  No 
matter  what  mechanical  and  surgical  methods  were  helpful  in 
these  cases,  still,  the  maintenance  of  the  best  possible  circulation 
of  good  blood  through  the  affected  area  and  through  the  spinal 
centers  in  close  connection  with  the  injured  areas  must  be  an 
extremely  important  factor  in  promoting  an  efficient  recovery. 
Treatment  should  be  kept  up  periodically  for  years  if  necessary. 

'Xesions  requiring  osteopathic  skill  are  so  obvious  that  the  slowest  may 
read  as  they  run.  .  .  .  The  three-minute,  specific-lesions  osteopath  should 
let  these  cases  alone ;  they  take  exquisite  care  and  patience  and  an  almost 
painful  regard  for  details.  The  words  "paralysis,"  "crippled,"  afflicted,"  are 
positively  and  entirely  eliminated  from  the  family  vocabulary.  .  .  .  During 
the  acute  stage,  rest  in  bed  is  essential.  As  soon  as  condition  permits,  begin 
giving  gentle  massage  every  three  hours  during  the  waking  time.  As  strength 
returns,  the  patient  is  given  joint  movements  with  the  massage,  then  resistive 
movements,  first  passively,  then  actively.  Go  slowly  rather  than  over-tire. 
Devise  plays  to  bring  the  muscles  into  use  .  ^  .  .  A  "walker"  is  of  great 
value.  ...  A  six-strand  wire  stretched  across  room  with  pulley  running 
along  it  offers  a  splendid  opportunity  for  leg  and  arm  work.  .  .  .  We  do 
not  lessen  his  difficulties  because  of  his  condition,  but  rather  increase  them. 
.  .  .  "He  loves  best  who  does  least."  .  .  .  There  is  never  a  time  to  be 
discouraged.  Persistent  and  conscientious  treatment  is  the  essential." — Evelyn 
R.  Bush. 


ERYSIPELAS  515 

"Paralyses  of  central  origin  can  be  but  little  benefited  by  osteopathic  gym- 
nastics, while  those  of  superficial  or  spinal  origin  may  be  greatly  aided.  If 
there  is  any  voluntary  motion  possible  in  the  fingers  or  toes,  the  nerve  cells 
controlling  the  musculature  to  these  parts  are  not  entirely  destroyed  and  new 
nerve  paths  may  be  developed  or  old  ones  restored.  To  accomplish  either, 
however,  it  requires  time  and  perseverance. 

"Briefly,  the  line  of  procedure  is  thorough  osteopathic  manipulation  fol- 
lowed by  assistive  and,  later,  resistive  movements.  Last  of  all,  single  move- 
ments are  prescribed.  Assistive  movements  mean  movements  willed  by  the 
patient,  but  executed  by  the  operator.  Resistive  movements  are  performed  by 
the  patient  and  resisted,  according  to  the  patient's  needs,  by  the  operator.  Single 
movements  are  exercises  performed  by  the  patient  without  outside  assistance  or 
resistance." — A.  A.  Gour. 

ERYSIPELAS 

(Erysipelatous  dermatitis;  the  rose;  St.  Anthony's  fire;  cryptogenetic  erysipelas; 

ignis  sacer;  wildfire) 

Erysipelas  is  an  acute,  specific,  infectious  disease,  characterized 
by  more  or  less  severe  febrile  reaction  and  a  peculiar  inflammation 
of  the  skin,  generally  of  the  neck  or  face.  This  inflammation 
exhibits  a  marked  tendency  to  spread,  to  induce  serous  infiltration 
and  suppuration  of  the  areolar  tissue,  and  to  aflFect  the  lymphatic 
vessels  and  glands. 

Etiology.  The  exciting  cause  is  the  streptococcus  erysipelatis 
of  Feheisen.  The  predisposing  causes  are  lowered  vitality,  exist- 
ence of  abrasions  and  wounds,  the  puerpural  state,  and  chronic 
alcoholism.  Lesions  of  the  upper  dorsal,  second  to  fifth,  of  the 
middle  and  lower  cervical  vertebrae,  affect  the  vasomotor  nerves 
either  directly  or  through  the  fifth  cranial  nerve  and  also  the 
lymphatic  circulation. 

"When  the  case  is  one  of  facial  type,  which  is  the  most  com- 
mon, then  I  generally  find  trouble  with  the  articulations  of  the 
inferior  maxilla,  the  cervical  vertebrae,  the  clavicles  or  the  upper 
ribs."— Dr.  A.  T.  Still. 

The  virus  clings  to  rooms  and  furniture  and  can  be  conveyed 
by  a  third  person.  The  incubation  period  is  from  two  to  seven 
days.  ■  • 

Diagnosis.  The  onset  is  usually  sudden  with  chill,  nausea, 
vomiting,  malaise,  headache,  and  pains  in  the  limbs.  The  tem- 
perature rises  to  104°  to  105°  F.  with  very  slight  remissions  dur- 
ing the  course  of  the  disease.  The  pulse  is  correspondingly  in- 
creased. The  tongue  is  coated,  diarrhea  or  constipation  is  present 
and  delirium  is  frequent.  The  cervical  lymph  glands  are  swollen. 
The  eruption  soon  follows  the  initial  chill  appearing  as  bright 
red  spots  upon  the  bridge  of  the  nose,  cheeks,  or  at  the  junction 
of  mucous  membrane  and  skin.  These  spots  rapidly  coalesce,  so 
that  the  external  symptoms  are  well  marked  within  twenty-four 
hours.  This  area  is  swollen,  firm,  hot  and  tender  to  the  touch,  pain- 


516  DISEASES  DUE  TO  COCCI 

ful,  and  pitting  on  pressure  which  also  increases  the  pain.  The 
edges  are  raised,  hard,  and  more  elevated,  thus  forming  a  sharp 
line  of  demarcation  from  the  surrounding  healthy  tissue. 

The  patient  complains  of  heat,  tingling,  itching,  and  burning 
of  the  infected  area.  Vesicles  and  blebs  are  frequent  upon  the 
surface  of  the  inflamed  area.  The  edema  of  the  surrounding  parts 
is  marked  so  that  when  the  face  is  involved  the  features  are  dis- 
torted out  of  all  recognition.  The  eruption  begins  to  subside  after 
five  or  six  days,  followed  by  moderate  desquamation  of  large  or 
small  flakes.  The  fever  declines  by  crisis.  The  mucous  mem- 
branes of  the  mouth  and  pharynx  may  become  involved.  In  the 
puerperal  form  the  genitals  may  be  involved. 

Phlegmonous  erysipelas  is  attended  by  marked  infiltration  and 
suppuration  of  the  areolar  tissues.  Erysipelas  ambulans  or  mi- 
grans is  shown  by  the  eruption  being  migratory  in  character, 
disappearing  in  one  place  to  appear  in  another  location.  The 
duration  is  from  ten  to  twelve  days. 

The  complications  include  local  suppuration  especially  small 
skin  abscesses ;  septicemia ;  ulcerative  endocarditis ;  edema  of  the 
larynx  from  extension  of  the  eruption ;  thrombosis  of  the  cerebral 
vessels ;  rheumatism ;  and  nephritis.  Elephantiasis  may  follow  fre- 
quent relapses.  The  irregular  fever,  the  early  spreading  eruption 
with  burning,  swelling,  tension,  and  sharply  defined  border,  and 
the  albuminous  urine,  will  distinguish  it  from  the  eruptive  fevers, 
eczema,  and  erythema. 

The  urine  is  scanty,  highly  colored,  albuminous,  and  may  con- 
tain the  specific  bacteria. 

The  specific  bacteria  may  be  found  in  the  bone  marrow  during 
the  acute  stage.  Pol3''morphonuclear  leucocytosis  is  almost  con- 
stant, and  is  proportionate  to  the  temperature  and  the  extension 
of  the  infection.  The  eosinophils  are  diminished  or  absent,  as  the 
leucocyte  count  falls  the  eosinophils  may  rise  considerably. 

Treatment.  The  patient  should  be  isolated  from  surgical  and 
puerperal  cases.  The  physician  attending  a  case  should  not  attend 
confinements  or  surgical  operations. 

The  correction  of  the  bony  and  muscular  lesions  w^herever 
found  is  important.  Increased  flexibility  of  the  lower  thoracic 
sjpinal  column,  and  of  the  entire  thorax,  is  usually  indicated. 

For  the  restlessness  and  insomnia,  treatment  of  the  upper 
cervical  region,  especially  the  deep,  steady  pressure  to  the  pos- 
terior muscles,  gives  relief.  • 

Diet  should  be  liquid  and  nutritious. 

For  the  local  treatment,  no  manipulation  can  be  used.  Hip- 
pocrates used  cold  water  as  an  application;  it  gives  much  relief. 
Clay  poultices  are  recommended.  Local  application  of  vaselin 
will  assist  in  relieving  the  tension.     In  migrating  erysipelas  ad- 


ACUTE  RHEUMATISM  517 

hesive  strips  along-  the  border  of  the  lesion  will  compress  lymphatics 
and  interfere  with  spreading. 

Prognosis.  The  outlook  is  favorable  except  in  alcoholics  and 
the  aged.  In  the  new-born,  erysipelas  of  the  navel  is  usually  fatal. 
In  the  ambulatory  form,  death  may  occur  from  exhaustion. 

ACUTE  ARTICULAR  RHEUMATISM 

(Inflammatory  rheumatism;   acute   rheumatic  polyarthritis;   rheumatic   fever) 

Acute  articular  rheumatism  is  an  acute,  noncontagious  febrile 
disease  characterized  by  a  polyarthritis,  a  tendency  to  hyperpy- 
rexia, a  special  tendency  to  involve  the  pericardium  and  endo- 
cardium, and  in  children  often  associated  with  chorea. 

Etiology.  The  infectious  agent  is  the  streptococcus  rheumati- 
cus  (Rosenow).  This  is  one  of  the  bacteria  subject  to  marked 
mutations  through  environmental  changes.  It  gains  entrance  into 
the  body  through  some  previous  infection,  and  in  about  90%  of 
cases  is  preceded  by  symptoms  of  acute  angina.  The  virus  may 
gain  entrance  into  the  blood  from  some  nidus,  as  tonsillar  pockets, 
abscesses  around  the  roots  of  the  teeth,  or  elsewhere. 

In  addition  to  the  presence  of  pus  in  the  body,  the  usual 
causes  of  lowered  immunity  are  of  etiological  importance.  Bony 
lesions,  especially  of  the  lower  thoracic  region,  as  well  as  lesions 
which  interfere  with  nutrition  or  excretion  are  important.  Young 
-adults  are  most  often  affected.  Overfatigue,  exposure  to  sudden 
change  in  temperature,  especially  cold  and  dampness,  and  other 
factors  of  diminished  resistance,  are  predisposing  factors. 

Pathology.  The  synovial  membrane  is  hyperemia,  there  is  swelling, 
effusion,  usually  turbid,  containing  albumin  but  seldom  purulent,  and  the  liga- 
mentous structures  are  swollen  and  the  cartilages  are  slightly  eroded.  The 
complicating  pericarditis,  endocarditis,  pleurisy,  and  myocarditis  show  the 
changes  of  an  inflammatory  process. 

Diagnosis.  In  some  cases  there  may  be  prodromal  symptoms 
of  a  feeling  of  malaise,  more  or  less  soreness,  these  beginning  very 
often  after  an  attack  of  tonsillitis,  and  rheumatic  pains  begin  in 
one  of  the  large  joints,  usually  the  knee,  wrist,  or  ankle.  The  usual 
order  of  attack  is  knee,  ankle,  shoulder,  wrist,  elbow,  hips,  hand  and 
foot.  In  other  cases  the  onset  may  be  abrupt  with  chilliness,  loss 
of  appetite,  and  the  arthritic  pain. 

The  temperature  may  not  be  very  high,  usually  between  100° 
and  103°  F.  but  hyperpyrexia  is  not  uncommon,  reaching  107°  to 
110°  F.  The  fever  usually  reaches  its  height  in  twenty-four 
hours  and  is  very  irregular.     The  defervescence  is  gradual. 

The  pulse  is  rapid,  full  and  soft.  The  tongue  is  usually  very 
large,  covered  with  a  thick  white  fur — "blanket"  tongue,  there  is 
great  thirst,  the  bowels  are  constipated,  the  mind  is  clear  except 


S18  DISEASES  DUE  TO  COCCI 

during  hyperpyrexia,  and  the  weakness  depends  upon  the  amount 
of  sweating. 

Arthritis.  The  joint  is  at  first  red,  hot,  swollen,  and  intensely 
painful ;  later  the  joint  may  assume  a  dead-white  appearance.  Fre- 
quently the  inflammation  rapidly  subsides  in  one  joint  to  appear 
in  another.  The  appearance  is  governed  by  the  law  of  parallelism, 
affected  joints  either  are  on  one  side  of  the  body  or  are  sym- 
metrical.   Pain  is  increased  by  motion  and  pressure. 

Sweating.  Marked  sweating  is  constant.  The  excretion  has  a 
peculiar  sourish  smell,  and  is  acid  at  first,  but  neutral  or  alkaline 
later.  Various  hair  follicles  and  cutaneous  glands  become  inflamed 
and  painful. 

Subcutaneous  nodules  fibrous  in  character  may  develop  over 
bony  ridges. 

The  severe  symptoms  usually  subside  in  about  fourteen  "to 
twenty-one  days.  There  is  no  disease  more  often  attended  with 
relapses. 

Subacute  form.  All  the  symptoms  are  less  pronounced.  The 
case  may  drag  on  for  weeks  or  months  and  finally  become  chronic. 
In  children,  it  may  be  associated  with  pericarditis  or  endocarditis. 

The  complications  include  endocarditis,  most  frequent  in  youth, 
affecting  oftenest  the  mitral  valve,  in  about  half  of  the  cases;  peri- 
carditis, less  frequent  but  insidious ;  myocarditis,  slight  or  pro- 
found ;  pleurisy ;  chorea ;  hyperpyrexia,  most  common  in  a  first 
attack,  often  attended  by  delirium  and  coma ;  skin  eruptions  as 
sudamina,  miliaria,  "pelioses"  or  small  red  petechial  spots  around 
the  ankles  and  purpura,  pharyngitis,  and  tonsillitis. 

The  heart  should  be  examined  daily.  Murmurs  of  hemic  or 
organic  origin  are  often  heard. 

The  blood  pressure  is  high. 

The  urine  is  scanty,  highly  colored,  often  loaded  with  urates, 
chlorides  diminished  or  absent,  acetonuria  is  present,  and  the  re- 
action is  markedly  acid. 

Blood.  There  is  an  excess  of  fibrin  but  the  coagulation  time  is 
increased.  Red  cells  show  a  moderate  anemia,  being  reduced  to 
3,000,000  cells  or  less.  The  lowest  count  is  at  the  height  of  fever 
and  regeneration  begins  with  defervescence.  It  is  rare  to  find 
nucleated  reds.  Hemoglobin  falls  to  55%  or  75%.  The  moderate 
leucocytosis  runs  parallel  with  the  severity  of  the  disease.  The 
proportional  relations  of  the  various  leucocytes  are  well  main- 
tained. The  eosinophiles  are  absent  at  the  outset,  present  during 
the  disease,  and  increased  during  convalescence. 

The  saliva  may  become  acid  and  contain  an  excess  of  sulpho- 
cyanides. 


ACUTB  RHEUMATISM  519 

Treatment.  The  patient  must  be  absolutely  at  rest  in  bed, 
warmly  covered.  "I  usually  treat  these  cases  from  one  to  four 
times  a  day  in  the  acute  stage  of  the  disease,  paying  particular 
attention  to  the  eighth  to  twelfth  dorsal.  Once  a  day  in  these 
treatments  I  gently  relax  and  spring  the  entire  spine.  Plaster 
bandages  and  splints  of  various  kinds  may  be  used,  but  I  personally 
use  snug  muslin  bandages  with  plenty  of  cotton  under  them,  espe- 
cially protecting  the  areas  where  the  large  blood  vessels  lie.  ,  ,  . 
Manipulation  of  any  kind  in  the  stage  of  acute  inflammation  is 
absolutely  contraindicated.  After  the  acute  inflammation  has  sub- 
sided passive  movement  of  the  joint  and  massage  above  and  below 
the  joint  certainly  aid  in  the  reparative  processes  and  help  to  pre- 
vent the  formation  of  pseudoankylosis  which  sometimes  follows  iii 
severe  cases.  .  .  .  The  next  consideration  is  the  tendency  to  endo- 
carditis and  pericarditis.  Osteopathic  treatment  to  the  areas  of 
the  spine  corresponding  with  the  innervation  of  the  heart  tends 
to  heighten  the  vitality  and  resisting  power  of  these  tissues.  I 
usually  apply  the  ice  bag  for  four  four-hour  periods  with  inter- 
vals of  two  or  three  hours,  and  this  application  may  be  increased 
or  lessened  depending  upon  the  severity  of  the  cardiac  symp- 
toms."— A.  D.  Becker. 

The  diet  should  be  fluid  during  the  acute  stage.  Milk  diluted 
with  mineral  water,  lemonade,  barley  water,  chicken  broth  should 
be  given  at  regular  and  short  intervals.  The  thirst  should  be  fully 
satisfied.  During  convalescence,  the  diet  should  be  more  ample 
but  nutritious,  using  red  meat  very  sparingly. 

Prognosis.  Recovery  is  the  rule  in  uncomplicated  cases.  When 
death  occurs,  it  usually  depends  upon  hyperpyrexia,  cardiac  com- 
plications, or  cerebral  endarteritis.  Sudden  death  is  due  to  myo- 
carditis. Recurrences  are  best  prevented  by  eliminating  all  predis- 
posing causes. 

Sequelae  may  in  a  large  measure  be  prevented  by  proper  treat- 
ment from  the  beginning  of  the  trouble. 


CHAPTER  XLVII 
DISEASES  DUE  TO  SPIROCHJETES 

RELAPSING  FEVER 

(Febris  recurrens;  famine  fever;  bilious  typhoid  fever;  spirillum  fever;  seven- 
day  fever) 

Relapsing  fever  is  an  acute,  infectious,  contagious,  epidemic, 
self-limited,  febrile  disease,  characterized  by  a  febrile  paroxysm 
lasting  about  six  days  accompanied  by  high  fever,  and  severe 
pains  in  the  legs  and  head ;  this  declining  by  crisis  is  succeeded  by 
an  afebrile  period  of  the  same  duration,  which  in  turn  is  followed 
by  a  relapse  similar  to  the  first  seizure. 

Etiology.  The  disease  is  caused  by  the  spirillum  or  spirochaeta 
obermeieri.  The  predisposing  factors  arc  overcrowding,  bad 
hygiene,  filth,  poor  food,  impure  air  and  destitution.  Structural 
causes  include  lesions  either  bony  or  muscular  interfering  with 
nutrition  and  with  circulation  through  the  spleen  and  liver. 

It  is  transmitted  by  fomites,  by  personal  contact  and  probably 
by  bed-bugs. 

Diagnosis.  The  incubation  is  from  five  to  eight  days,  some- 
times from  one  to  twenty-one  days,  with  some  complaints  of 
malaise,  lassitude  and  fleeting  pains. 

The  invasion  is  sudden  with  heavy  chill  and  temperature  to 
105°  to  106"  F.  on  the  first  or  second  days,  soft  pulse,  110  to  130, 
hemic  murmur,  frontal  headache  and  vertigo,  lancinating  pains 
most  marked  in  the  calves  of  the  legs,  anorexia,  nausea,  and  vomit- 
ing, intense  thirst,  tongue  with  a  marked  white  fur,  bowels  con- 
stipated and  great  physical  weakness. 

The  sense  of  fullness  in  the  upper  abdomen  is  due  to  the 
enlargement  of  the  liver  and  spleen.    Catarrhal  jaundice  is  common. 

About  the  seventh  day  the  symptoms  are  aggravated,  tem- 
perature reaches  107°  to  108°  F.,  the  pulse  120  to  130,  there  may 
be  slight  delirium,  and  death  seems  imminent  when  sweating  takes 
place,  the  bad  symptoms  rapidly  abate,  and  the  crisis  is  estab- 
lished. Within  a  few  hours  the  patient  feels  comparatively  com- 
fortable and  is  ravenously  hungry. 

On  the  fourteenth  day  the  symptoms  all  recur,  perhaps  intensi- 
fied, these  continue  for  about  four  days  when  second  crisis  is 
passed. 

From  one  to  five  relapses  are  recorded.  These  occur  at  about 
seven  day  intervals. 

520 


SYPHILIS  521 

Malignant  form  (Bilious  typhoid  fever;  septic-bilious  relapsing 
fever).  The  intensity  of  the  symptoms  of  the  ordinary  form, 
vv^ith  bilious  or  bloody  vomiting,  diarr.heic  stools  containing  bile- 
pigments,  jaundice  on  the  fourth  to  sixth  day,  and  delirium  indi- 
cate this  form.  More  serious  symptoms  are  collapse,  purple  nose, 
weak  pulse,  rigidity  of  the  abdominal  muscles,  tenderness  in  the 
epigastrium,  and  cold,  clammy  skin.  The  mortality  is  high.  Re- 
covery takes  place  rapidly  within  two  days  if  at  all. 

Pregnant  women  usually  abort.  Other  complications  are 
bronchitis,  pleurisy,  jaundice,  albuminuria  and  hematuria,  paral- 
ysis, ophthalmia,  pneumonia,  dysenteric  diarrhea,  and  hem- 
orrhages, all  rare. 

Blood.  The  examination  of  a  fresh  smear  obtained  during  a 
febrile  paroxysm  will  show  the  spirochaeta  obermeieri.  During  the 
afebrile  periods,  peculiar,  highly  refractive  bodies  resembling 
diplococci  are  found.  These  are  thought  to  be  spores  and  are 
especially  numerous  just  before  an  attack. 

Serum  diagnosis  is  by  Lowenthal's  reaction  which  resembles 
Pfeiffer's  phenomenon  rather  than  agglutination.  Leucocytosis 
is  usually  present.  - 

Treatment.  Immediate  isolation  and  disinfection  are  neces- 
sary to  prevent  the  spread  of  the  disease.  Put  the  patient  to  bed 
in  a  clean,  well-ventilated  room.  Give  a  general  manipulative 
treatment  adjusting  such  structures  as  need  it.  Pay  particular 
attention  to  the  liver  and  spleen.  Keep  the  excretory  systems 
active.  Look  carefully  to  the  lumbar  region  for  lesions  and  relax 
carefully  to  control  the  pain. 

The  diet  must  be  liquid  and  easily  digested  as  the  digestive 
powers  are  low  from  lack  of  food. 

Careful  nursing  is  necessary.  Treat  the  symptoms  as  they 
arise. 

Prognosis.    In  simple  cases,  recovery  is  the  rule. 

Prophylaxis.  Isolation  of  suspected  cases,  disinfection  of  the 
patient,  his  excretions,  and  all  articles  used  by  him  is  necessary. 


SYPHILIS 

Syphilis  is  a  chronic  infectious  disease  due  to  the  presence  of 
the  treponema  pallidum  (spirochaeta). 

Etiology.  The  treponema  pallidum  is  a  spirillum  about  one- 
half  micron  or  less  in  thickness  and  from  eight  to  forty  or  more 
microns  in  length.  It  may  be  transmitted  from  one  person  to 
another  by  direct  contact  or  by  intermediate  objects.  It  may  be 
transmitted  by  the  ovum  or  the  spermatozoon  to  the  embryo  and 


522  DISEASES  DUE  TO  SPIROCHETES 

thus  it  is  a  hereditary,  infectious  disease,  the  only  one  which  is 
certainly  recognized. 

History,  The  site  of  the  infection  shows  the  primary  lesion 
which  is  called  a  chancre.  This  begins  as  a  small  red  pustule, 
which-  rapidly  increases  in  size,  then  breaks  down  in  the  center 
forming  a  small  ulcer.  The  margins  of  the  sore  are  undulated  and 
the  ulcer  extends  somewhat  beneath  this  undulated  edge,  giving  a 
characteristic  appearance  to  the  chancre.  Occasionally  this  ulcer 
is  very  small  and  may  not  attract  attention.  In  about  three  fourths 
of'all  cases  the  ulcer  is  situated  upon  the  genitalia,  and  is  acquired 
through  illicit  sex  relations..  In  Russia,  about  three  fourths  of  all 
cases  are  acquired  through  kissing,  and  the  chancre  is  situated  upon 
the  lip.  Surgeons  and  obstetricians  may  suffer  infection  upon  the 
fingers.  The  use  of  vaccine  from  the  sores  of  vaccination  may  be  a 
means  of  transmitting  syphilis.  Rarely  the  infection  may  be  carried 
by  intermediate  objects,  as  the  bed  clothing,  the  common  use  of  a 
fountain  syringe,  public  drinking  cups,  public  towels,  and  in  other 
ways  too  numerous  to  mention.  The  favorite  site  of  the  chancre 
is  a  mucous  membrane,  though,  as  has  already  been  suggested,  it 
may  appear  upon  the  skin  anywhere  in  the  body.  Chancre  heals 
usually  within  a  few  days.  The  neighboring  lymphatic  glands  are 
usually  swollen,  and  this  increase  in  size  usually  persists. 

The  secondary  stage  appears  from  six  weeks  to  six  months 
after  the  primary  lesion.  There  is  a  slight  fever,  rarely  above  101°, 
with  a  general  feeling  of  malaise  and  other  vague  symptoms. 
Aching  in  the  bones  is  rather  characteristic.  The  lymphatic  nodes 
over  the  body  generally  enlarge.  A  slight  anemia  is  frequently 
present.  Within  a  few  days  or  weeks  of  these  prodromal  symp- 
toms, the  eruptions  occur.  Those  upon  the  skin  are  extremely 
variable.  An  erythematous  eruption  is  usually  first  and  is  most 
abundant  upon  the  chest,  other  parts  covered  with  clothing  and 
occasionally  the  forehead.  A  papular  eruption  is  very  common, 
the  papules  are  of  various  sizes  and  appear  chiefly  upon  the  flexor 
surfaces.  Mucous  patches  appear  upon  the  mucous  surfaces. 
The  distribution  of  the  syphilids  is  usually  very  symmetrical.  The 
outlines  are  rounded,  and  may  present  a  map-like  appearance  with 
a  coppery  tinge.  Later  eruptions  may  be  pustular  or  tuber- 
cular. These  are  usually  gregarious  and  symmetrically  placed. 
Other  symptoms  which  occasionally  appear  during  the  secondary 
stage  are  alopecia,  laryngitis,  iritis,  choroiditis,  retinitis  and  other 
vague  and  apparently  causeless  inflammations  of  the  mucous  mem- 
branes of  the  body,  the  nails,  the  hair  and  the  skin.  The  secondary 
stage  may  last  a  few  months  to  a  year,  when  the  symptoms  dis- 
appear. There  is  one  form  called  late  secondary  syphilis  in  which 
the  symptoms  of  the  secondary  stage  may  not  appear  for  several 
years  after  the  primary  lesion.     Usually  the  patient  enjoys  good 


SYPHILIS  523 

health  for  some  months  or  years  after  the  conclusion  of  the  sec- 
ondary stage,  but  this  is  not  invariably  true. 

The  tertiary  stage  is  characterized  by  the  appearance  of  a 
peculiar  skin  eruption.  This  is  pustular  at  first,  the  pustules 
break  and  form  ulcers  with  hard  and  sometimes  laminated  scabsJ 
Syphilitic  tubercles  are  especially  characteristic  of  the  tertiary 
stage.  Both  of  these  lesions  in  healing  leave  scars  which  fre- 
quently are  of  a  coppery  color,  due  to  the  stain  of  extravasated 
blood.  Gummata  are  typical  of  the  syphilitic  manifestations, 
and  consist  of  lymphoid,  plasma  and  epithelioid  cells  with  leuco- 
cytes. Great  masses  of  these  cells  undergo  fatty  degeneration 
and  ultimately  a  gummy  or  pasty  mass  results.  These  may  break 
down  with  extensive  ulceration  or  they  may  be  slowly  absorbed 
with  no  particular  ill  effects.  No  organ  of  the  body  is  free  from 
invasion  by  the  gummata.  When  they  occur  upon  bones,  they 
may  be  very  painful,  but  generally  it  is  characteristic  of  the  syph- 
ilitic lesion  to  cause  little  or  no  sensory  disturbance.  Amyloid 
degeneration,  fibrosis,  and  arteriosclerosis  are  important  constitu- 
tional changes  following  syphilis. 

Syphilis  of  the  bones  includes  synovitis,  arthritis  and  the 
effects  of  the  osseous  nodes  and  gummata  around  the  joints.  The 
arthritis  associated  with  osteomata  is  associated  with  very  severe 
nocturnal  pain.  The  joint  symptoms  are  rather  characteristic  of 
the  secondary  stage,  but  are  often  present  in  the  tertiary. 

Syphilis  of  the  kidneys  usually  appears  in  the  tertiary  stage. 
It  includes  amyloid  degeneration,  chronic  and  interstitial  neuritis 
and  gummata.  Syphilis  of  the  spleen  and  other  lymphatic  glands 
includes  amyloid  degeneration  and  vascular  lesions.  Syphilis  of 
the  mouth  and  of  the  rectum  are  not  uncommon  and  are  asso- 
ciated with  ulcers  whose  effects  may  be  fatal.  In  the  case  of  the 
rectum  a  gradual  stenosis  may  lead  to  death.  Syphilis  of  the 
lungs  is  extremely  rare.  Fibrous  infiltration  or  interstitial  pneu- 
monia or  gummata  may  be  present.  Pulmonary  syphilis  is  not 
easily  distinguished  from  pulmonary  tuberculosis  except  by  finding 
the  infectious  agents.  Both  infections  may  be  present  in  any  case. 
Syphilitic  endocarditis  and  myocarditis  cannot  be  certainly  diag- 
nosed ante-mortem.  Syphilitic  endarteritis  and  gummatous  peri- 
arteritis are  important  factors  in  the  pathology  of  atheroma  and 
aneurysm,  (q.  v.) 

Syphilis  of  the  liver  may  be  congenital  or  acquired.  The  dis- 
ease is  manifested  in  its  congenital  form,  either  as  a  diffused  cellu- 
lar infiltration  which  produces  at  first  enlargement  and  hardening, 
later,  atrophic  changes  and  irregularities;  or  as  a  gumma. 

Acquired  hepatic  syphilis  may  show  itself  as  diffused  inter- 
stitial hepatitis,  single  or  multiple  gummata,  amyloid  disease,  en- 
darteritis, or  chronic  fibrous  perihepatitis.    Jaundice  in  the  course 


524  DISEASES  DUE  TO  SPIROCHETES 

of  syphilis  and  severe  pain  may  be  present.  Symptoms  of  portal 
obstruction  may  occur  as  in  ordinary  cirrhosis,  or,^  sometimes,  the 
symptoms  suggest  abscess  or  cancer.  The  diagnosis  is  made  by 
the  history,  and  the  results  of  the  Wassermann  or  other  specific 
tests.  The  outline  of  the  liver  is  irregular  and  the  enlargement  is 
not  uniform.  If  the  gummata  are  accessible  to  palpation,  they 
appear  like  flattened  hemispheres,  sometimes  several  being  made 
out  on  the  surface  of  the  enlarged  organ.  If  no  syphilitic  history 
is  obtained,  scars  in  the  throat,  nodes  on  the  bones,  or  other  signs 
of  syphilis  may  be  found. 

Syphilis  of  the  heart  is  a  rather  uncommon  manifestation, 
usually  affecting  the  myocardium  with  gummata  or  diffused  fibro- 
sis, or  more  rarely  amyloid  infiltration,  and  is  occasionally  a  cause 
of  aortic  regurgitation,  the  heart  usually  not  enlarged,  and  clin- 
ically manifested  by  rapid,  irregular  pulse,  palpitation,  dyspnea, 
and  sometimes  anginoid  attacks. 

Syphilitic  Laryngitis.  A  common  manifestation  of  this  disease 
appears  as  a  diffuse  nondistinctive  catarrhal  laryngitis  or  as  mu- 
cous patches,  three  to  nine  months  after  infection,  or  as  gummata, 
either  in  acquired  or  congenital  syphilis.  The  main  symptoms  are 
slight  hoarseness  and  cough,  somewhat  painful  deglutition,  expec- 
toration of  free  muco-purulent  discharge  streaked  with  blood  or 
blackened  shreds  from  an  ulcer,  and  syphilitic  evidences  elsewhere 
in  the  body.  Laryngeal  examination  shows  superficial  whitish 
ulcers  in  secondary  syphilis.  Small,  round,  symmetrical  gummata 
rapidly  becoming  deep,  punched-out,  dark  red,  somewhat  indurated 
ulcers  with  a  mucopurulent  secretion  and  necrosed  tissue  mark  the 
third  stage  or  there  are  deformed  cicatrices,  producing  more  or  less 
stenosis.  The  mucosa  is  hyperemic  and  injected.  There  is  more  or 
less  tenderness  on  pressure  with  the  deep  ulceration.  The  history, 
peculiar  lesions,  Wassermann  reaction  and  other  laboratory  tests 
distinguish  this  from  tubercular  laryngitis,  although  tuberculosis 
may  be  present  elsewhere  in  the  body.  Under  treatment  for  the 
underlying  condition,  the  ulcers  heal  rapidly,  but  the  resulting  cic- 
atrices may  impair  the  voice. 

Syphilis  of  the  Central  Nervous  System.  The  effects  of  syph- 
ilis upon  the  central  nervous  system  are  extremely  variable.  Gum- 
mata may  appear  anywhere  upon  the  meninges  and  within  the  nerve 
matter.  The  symptoms  thus  produced  resemble  those  produced 
by  tumors  of  any  kind  in  the  same  locations.  The  dura  is  espe- 
cially subject  to  a  gummy  pachymeningitis.  The  symptoms  pro- 
duced in  this  way  are  chiefly  due  to  pressure  upon  the  nerve 
trunks.  The  syphilitic  lesions  of  the  blood  vessels  lead  to  pro- 
found injury  in  the  brain  and  spinal  cord.  Thrombosis  or  obliter- 
ing  endarteritis  occurring  in  the  brain  leads  to  infarction.     The 


SYPHILIS  525 

infarcted  area  undergoes  digestion  and  softening.  The  examina- 
tion of  the  syphilitic  brain  usually  shows  thickened  gummy  dura 
mater,  a  thickened  milky-looking  pia-arachnoid,  and  adhesions  are 
likely  to  be  found  between  these  layers  of  the  meninges  and  the 
brain  itself.  The  blood  vessels  are  tortuous  and  irregular.  Capil- 
lary hemorrhages  are  frequent.  Succession  of  aneurisms  may 
cause  certain  arteries  to  resemble  a  chain  of  beads.  Areas  of  soft- 
ening or  areas  in  which  marked  overgrowth  of  neuroglia  has 
occurred  may  be  present.  Gummata  may  be  single  or  multiple, 
large  or  small. 

The  parasyphilitic  diseases  occur  several  years  or  two  or  more 
decades  after  the  primary  lesion.  The  symptoms  of  this,  which  is 
sometimes  called  the  quaternary  stage,  are  usually  limited  to  the 
central  nervous  system  and  are  due  to  various  degenerations  in 
the  nerve  matter.  Locomotor  ataxia,  taboparalysis,  and  paralytic 
dementia  are  the  most  common  of  the  parasyphilitic  diseases.  It 
is  frequently  the  case  that  these  diseases  appear  in  patients  in 
whom  the  primary  and  secondary  manifestations  were  very  trivial. 
Indeed  it  is  not  rare  to  find  these  diseases  occurring  in  patients 
who  had  not  previously  known  themselves  to  have  been  infected 
and  yet  in  whom  the  laboratory  examinations  have  demonstrated 
almost  certainly  the  usual  cause  of  these  diseases.  There  is  some 
reason  to  believe  that  either  by  some  specific  reaction  or  as  the 
result  of  some  internal  secretion  the  nerve  cells  are  able  to  either 
neutralize  the  effects  of  the  syphilitic  poison  or  to  deter  the  rapid 
multiplication  of  the  treponema.  Either  because  this  antitoxin- 
producing  activity  exhausts  the  neurons  or  because  the  onset  of 
a  less  vigorous  time  of  life  prevents  the  neurons  from  continuing 
these  protective  activities,  the  nerve  cells  and  fibers  do  undergo 
degeneration  at  almost  any  time  after  middle  life.  Cerebral  syph- 
ilis which  usually  occurs  during  the  tertiary  stage  may  be  asso- 
ciated with  a  most  complicated  disease  picture.  Paralysis  either 
sensory  or  motor  or  of  the  Brown-Sequard  type,  epileptic  attacks, 
many  hysterical  phenomena,  paralysis  either  of  the  upper  or  lower 
neuron  type,  retinal  hemorrhages,  atrophy  of  the  optic  nerve  are 
only  a  few  of  the  effects  of  syphilis  in  the  brain.  The  gumma  in 
the  brain  presents  all  of  the  symptoms  of  the  ordinary  brain 
tumor. 

Hereditary  Syphilis.  Except  for  chancres  the  symptoms  already 
mentioned  appear  in  hereditary  syphilis.  Very  frequently  the 
products  of  syphilitic  conception  die  very  early  in  pregnancy.  A 
considerable  percentage  of  those  born  at  term  are  born  dead  and 
of  those  born  living  about  one  fourth  die  within  the  first  half 
year  of  their  existence.  Of  those  who  live,  many  are  mentally  de- 
ficient, epileptic  or  become  subject  to  the  parasyphilitic  diseases 
rather  early  in  life.    The  newborn  child  may  be  greatly  emaciated 


526  DISEASES  DUE  TO  SPIROCHETES 

and  may  or  may  not  suffer  from  any  one  or  more  of  a  long  list 
of  skin  and  mucous  lesions.  Most  of  the  children  born  alive  are, 
however,  born  plump  and  apparently  perfectly  w^ell.  Any  time 
within  the  first  few  months  of  life  a  coryza  first  appears,  this  gives 
the  symptoms  of  an  ordinary  bad  cold  and  the  child  has  snuffles, 
skin  lesions  appear  usually  within  a  few  days,  the  liver  and  spleen 
enlarge,  and  other  symptoms  of  the  secondary  stage  appear.  The 
child  is  fortunate  if  these  are  fatal.  If  recovery  occurs  from  these 
syrriptoms,  or  if  they  have  not  appeared  at  all,  the  later  symptoms 
of  inherited  syphilis  may  be  expected,  such  as  an  earthy  tint  of 
the  skin,  retarded  growth,  imperfectly  developed  scalp,  a  general 
infantile  appearance  throughout  childhood,  a  boat-shaped  skull 
and  deformities  of  the  bones.  The  results  of  peritoneal  inflam- 
mations are  very  common.  Scars  upon  the  skin  with  rounded  or 
map-like  outlines  are  usually  located  around  the  mouth  and  nose, 
upon  the  palate  or  over  the  lumbo-sacral  region. 

Hutchinson's  Triad  includes  the  Hutchinson  teeth — that  is, 
incisors  ^which  are  very  thin  and  with  crescent-shaped  notches  in 
them ;  otorrhea,  with  deafness ;  and  interstitial  keratitis  and  iritis, 
affecting  the  eyes  in  succession. 

Diagnosis.  '  The  diagnosis  of  syphilis  may  be  extremely  difB- 
cult  or  very  easy.  For  many  reasons  patients  often  deny  the  exist- 
ence of  the  disease  and  conceal  as  much  as  they  can  any  history 
which  might  lead  to  its  diagnosis.  This  diflficulty  would  be  made 
greatly  less  if  the  fact  that  syphilis  is  very  frequently  contracted 
innocently  could  be  impressed  upon  the  people  in  general.  The 
examination  of  the  skin  should  show  the  characteristic  scars  in  the 
locations  already  mentioned.  Examination  of  the  serum  expelled 
from  the  tonsil  usually  shows  the  presence  of  the  treponema  palli- 
dum during  the  primary  and  secondary  stages.  The  fact  that  the 
syphilitic  eruption  usually  causes  neither  pain  nor  itching  should 
be  borne  in  mind.  The  Wassermann  method  with  its  modifications 
and  the  Noguchi  test  are  fairly  reliable,  especially  if  the  same  find- 
ings are  reported  from  two  or  more  different  tests.  The  cerebro- 
spinal fluid  probably  shows  lymphocytosis  throughout  the  lifetime 
of  a  syphilitic  patient.  In  congenital  syphilis,  the  X-ray  may  show 
characteristic  changes  in  the  bones,  especially  in  the  radius  and  the 
fibula. 

Treatment.  The  use  of  mercury  and  the  iodides  was  long  con- 
sidered absolutely  satisfactory  and  specific  for  syphilis.  Since  the 
vogue  of  the  newer  arsenic  preparations,  the  evils  of  the  older 
methods  have  been  rather  freely  discussed.  The  arsenic  is  intended 
to  kill,  or  to  prevent  the  multiplication,  of  the  treponema,  without 
injury  or  at  least  with  little  injury  to  the  body.  The  ignorant 
use  of  these  methods  is  to  be  condemned — if  they  are  the  best 


SYPHIUS  527 

things  for  the  patient,  he  should  be  referred  to  specialists  in  this 
line  of  therapy,  if  this  is  possible. 

The  value  of  the  nondr«g  methods  is  yet  to  be  seen.  All  such 
methods  are  based  upon  securing  the  greatest  possible  efficiency 
of  the  organs  of  elimination,  with  good  body  nutrition. 

Oxygen  Treatment.  The  treponema  pallidum  is  absolutely 
anerobic.  Cultures  must  be  very  carefully  protected  from  oxygen, 
or  they  die  speedily.  This  fact  has  been  made  the  basis  for  a 
method  of  treatment.  The  attempt  is  made  to  facilitate  the  oxida- 
tion processes  to  the  utmost  extent.  This  is  done  by  means  of 
breathing  exercises,  which  not  only  oxygenate  the  blood  but  also 
provide  good  circulation  through  the  red  bone  marrow  and  exer- 
cise good  effects  upon  digestion;  by  increased  muscular  activity, 
as  in  rowing  or  football,  and  hard  work,  as  digging,  etc. ;  by  a  diet 
largely  of  green  vegetables  and  iron-containing  foods,  including  a 
moderate  amount  of  red  meats  but  little  starch  or  fats;  by  full 
water  drinking,  and  the  use  of  such  fruits  as  have  a  diuretic 
eflfect.  Citrus  fruits  are  especially  commended.  Active  elimination 
of  all  toxins  is  to  be  promoted  by  baths,  enemas,  massage,  out- 
door living,  and  the  drinking  of  much  water.  Alcohol  is  forbidden, 
both  on  account  of  its  effect  upon  the  nerve  tissue  and  also  because 
of  its  effect  in  using  up  the  oxygen  and  the  water  which  are 
needed  in  destroying  and  eliminating  the  infectious  ap-ent.  Tobacco 
is  forbidden  on  account  of  the  effect  upon  the  body,  and  smoking 
on  account  of  the  carbon  dioxid  which  is  thus  taken  into  the  body. 
Excesses  of  all  kinds  are  forbidden,  both  on  account  of  their 
direct  injury  upon  the  nerve  and  other  tissues,  and  also  because 
they  diminish  the  oxidation  processes,  and  lessen  the  elimination 
of  toxins. 

Prophylaxis.  Prevention  is  difficult  on  account  of  the  fact 
that  the  disease  is  so  frequently  contracted  as  the  result  of  illicit 
sex  relations.  The  fact  that  it  is  so  often  contracted  innocently  is 
forgotten,  whereas  that  fact  should  be  especially  emphasized,  in 
order  that  concealment,  with  its  opportunities  for  spreading  the 
disease  may  be  superseded  by  better  sanitary  methods.  Any  othex 
contagious  disease,  hidden  as  a  crime,  would  certainly  spread 
much  more  rapidly ;  syphilis,  recognized  as  an  infection  presumably 
the  result  of  accident,  could  be  controlled  much  more  easily  than 
when,  as  now,  it  is  held  to  be  proof  of  immorality  of  a  certain  type. 
The  discussion  of  methods  dealing  with  what  is  generally  called 
the  "social  crime"  is  beyond  the  scope  of  this  book ;  the  solution 
of  the  problems  connected  with  this  aspect  of  human  life  will 
solve  many  other  problems,  as  well  as  those  of  syphilis. 

Marriage  should  be  forbidden  until  at  least  two,  and  better 
four,  years  after  active  symptoms  have  disappeared.  The  danger 
to  the  wife  includes  that  of  the  disease  itself,  and  also  the  risk  of 


528  DISEASES  DUE.  TO  SPIROCHETES 

the  miscarriages  due  to  the  death  of  embryo  or  fetus,  and  other 
obstetrical  complications  due  to  the  effects  of  the  disease.  Still 
births  and  early  death,  inherited  syphilis,  and  many  deformities  of 
body  and  brain,  without  the  active  manifestations  of  the  syphilitic 
disease,  are  some  of  the  effects  produced  upon  the  offspring  of 
syphilitic  parents. 

.  HEMORRHAGIC  JAUNDICE 

(Weil's  disease;  acute  hemorrhagic  icterus) 

This  disease  is  becoming  more  frequently  reported  among  soldiers.  It 
may  be  identical  with  acute  febrile  icterus  (page  566).  Hemorrhagic  jaundice 
is  an  acute  infectious  disease  characterized  by  hemorrhages,  fever,  muscular 
pains,  jaundice  and  usually  very  rapid  recovery  after  several  weeks'  apparently 
very  severe  illness. 

Etiology.  The  infectious  J^ent  is  the  spirochete  icterohemorrhagica 
(spirochete  nodosum).  It  is  present  in  considerable  numbers  in  the  urine  of 
those  affected.  It  spreads  with  e^se  as  the  result  of  trench  life,  during  the 
war ;  the  use  of  bathing  pools,  or  other  insanitary  conditions. 

Diagnosis.  The  symptoms  are  as  given  in  the  definition.  Nephritis, 
urticaria,  cerebral  symptoms,  as  coma,  delirium,  and  other  complications  may 
be  present.  The  stools  are  pale ;  the  infectious  agent  may  be  recognized  most 
easily  in  the  urine.  Injection  of  the  urine  into  guinea  pigs  produces  the  dis- 
ease.   The  spirochetes  can  be  isolated  from  the  blood  and  urine  of  the  pig. 

Treatment.  This  is  symptomatic  and  palliative.  The  patient  must  be 
removed  from  unclean  surroundings,  the  excretions  carefully  disinfected,  and 
the  fever  treated  as  in  other  infectious  diseases. 

Prognosis.  In  uncomplicated  cases  recovery  begins  at  about  the  fifth 
week;  convalescence  is  rapid.  The  illness  may  persist  for  two  months  or 
more.  In  severe  attacks  death  may  occur  from  exhaustion,  during  coma  or 
delirium,  or  from  hemorrhages. 


CHAPTER  XLVIir 
DISEASES  DUE  TO  ANIMAL  ASSOCIATES 

PLAGUE 

(Bubonic  plague;  black  death;  oriental  plague;  pest  or  pestis) 
Plague  is  an  acute,  infectious,  contagious  disease,  occurring  in 
epidemics,  characterized  by  great  virulence  and  rapid  course, 
accompanied  by  an  inflammation  of  the  lymph  glands  (buboes) 
or  by  pulmonary  inflammation,  and  due  to  the  presence  in  the 
blood  and  tissues  of  the  bacillus  pestis. 

Etiology.  The  predisposing  causes  are  insanitary  conditions, 
filth,  overcrowding,  and  warm  weather.  It  is  transmitted  chiefly 
by  fleas  which  spread  the  disease  among  rats,  mice,  cats,  and 
ground  squirrels  and  to  man.  These  animals  die  of  the  disease 
in  large  numbers.  They  have  the  disease  in  a  chronic  form,  living 
months,  and  spreading  the  infection  widely.  "Every  city  should 
be  surrounded  by  a  wid"e  zone  entirely  freQ.from  these  animals." — 
C.  A.  Whiting. 

The  contagion  seems  to  be  in  the  skin,  the  mucous  membranes 
of  the  nose  and  pharynx.    The  incubation  is  two  to  five  days. 

Diagnosis.  Premonitory  symptoms  are  absent  or  very  slight. 
Invasion  is  usually  sudden  with  very  high  fever  which  drops  with 
the  appearance  of  the  buboes,  profuse  sweating,  unquenchable 
thirst,  repeated  attacks  of  vomiting,  diarrhea  or  constipation,  head- 
ache, suffusion  of  the  eyes,  sometimes  rigors,  great  prostration  and 
lassitude,  delirium.  Ecchymoses  and  petechial  spots  are  common. 
The  face  has  an  anxious  or  dazed  expression,  the  speech  is  thick 
and  indistinct,  the  hearing  dulled,  the  gait  staggering,  and  the 
tongue  is  swollen,  furred,  dry  and  brown. 

The  Bubonic  form  occurs  in  78%  of  cases.  Buboes  appear  in 
the  groin,  axilla,  or  near  the  jaw  on  the  second  to  the  fifth  days. 
They  are  usually  single,  large  and  very  tender.  There  is  enlarge- 
ment of  the  spleen.  In  favorable  cases  the  convalescence  begins 
slowly  from  the  sixth  to  the  tenth  day,  but  the  buboes  continue 
to  enlarge,  break  down,  and  are  discharged  in  the  form  of  puslike 
material  and  sloughs,  lasting  for  weeks. 

In  the  Pneumonic  form  there  are  no  buboes.  High  fever,  pros- 
tration, cough,  profuse,  watery,  blood-stained  sputum  which  is 
almost  a  pure  culture  of  the  bacillus,  and  moist  rales  are  char- 
acteristic. The  physical  signs  are  not  proportionate  to  the  severity 
of  the  symptoms.    The  mortality  is  very  high. 

529 


530  DISEASES  FROM  ANIMALS 

In  the  septic  or  septicemic  form  the  patient  succumbs  in  three 
or  four  days  from  the  intense  virulence.  The  buboes  do  not  appear. 
The  ambulatory  (pestis  ambulans  or  pestis  minor)  is  marked  by 
a  few  days  of  fever  and  swelling  of  glands  in  the  groin.  The 
symptoms  are  very  mild.  These  cases  are  a  great  danger  to  the 
cotnmunity  as  the  bacilli  are  contained  in  the  urine  and  stools  and 
hence  spread  the  disease. 

Blood.  Bacillemia  occurs.  There  is  a  leucocytosis  of  20,000  to 
30,000  cells  during  the  active  stage.  Both  polymorphonuclears  and 
lymphocytes  are  increased.  The  eosinophiles  are  normal  or  de- 
creased. 

Agglutination  of  the  plague  bacillus  occurs.  It  is  rather  diffi- 
cult to  obtain  as  a  mild  degree  of  spontaneous  agglutination  is 
liable  to  occur  with  normal  blood. 

Treatment.  The  treatment  is  mainly  symptomatic.  The  cough, 
fever,  and  toxemia  must  be  met  here,  as  in  other  diseases.  A 
very  nutritious  diet,  mainly  liquid,  must  be  given.  Fruit  and 
vegetable  juices  with  plenty  of  water  must  be  given  freely  during 
the  fever.    A  diet  of  fresh  pineapple  has  been  recommended. 

Prognosis.  The  mortality  is  high  in  all  forms.  Death  occurs 
on  or  about  the  third  day,  or  later  from  exhaustion  or  complica- 
tions.    Recovery  begins  about  a  week  from  the  onset. 

Prophylaxis.  Rigorous  isolation  is  continued  for  a  month  after 
recovery.  Disinfection  of  all  excreta,  discharges,  clothes,  and  uten- 
sils must  be  thorough.  Rats,  mice  and  ground  squirrels  must  be 
exterminated  as  far  as  possible  and  their  bodies  burned.  Special 
care  must  be  taken  at  seaports.  Attendants  and  housemates  of 
a  patient  must  be  disinfected  and  quarantined  for  ten  days. 


HYDROPHOBIA 

(Rabies;  lyssa  humana) 

Hydrophobia  is  an  acute  infectious  disease,  occurring  in  ani- 
mals but  communicable  to  man  by  inoculation  and  characterized 
by  intense  tonic  spasm  beginning  in  the  larynx;  delirium,  coma 
and  usually  death. 

Etiology.  The  infectious  agent  is  probably  a  protozoan,  which 
appears  in  the  large  ganglion  cells  of  the  brain,  as  one  of  the 
"Negri  bodies."  The  same  organism,  though  less  easily  recog- 
nizable, is  found  in  the  saliva  and  elsewhere.  It  is  transmitted  by 
the  bites  of  infected  animals,  and  the  organism  follows  the  nerve 
trunks  to  the  cord  and  brain.  Bites  upon  the  face  thus  result  in 
more  certain  and  more  speedy  appearance  of  the  symptoms,  both 
on  account  of  the  plentiful  nerve  supply  and  the  short  distance 


HYDROPHOBIA  531 

the  infection  has  to  travel  in  order  to  reach  the  brain.  The  bite  of 
an  animal  known  to  be  suffering  from  rabies  is  not  always  followed 
by  the  appearance  of  the  symptoms.  The  bite-  of  an  animal  not 
suffering  from  rabies  cannot  possibly  produce  the  disease.  Chil- 
dren are  more  susceptible  than  adults. 

Diagnosis.  Under  ordinary  circumstances,  when  there  is  reason 
to  suspect  rabies  in  a  dog  or  cat,  it  is  much  better  not  to  kill  the 
animal,  but  to  keep  it  alive,  confined  in  a  large,  comfortable  cage, 
where  it  can  be  watched  and  well  cared  for.  If  it  shows  no  sign 
of  further  disease,  or  if  symptoms  of  some  other  disease  appear, 
the  animal  is  evidently  not  rabic.  If  the  animal  dies,  or  has  been 
unwisely  killed,  the  brain  should  be  placed  on  ice  and  sent  to  the 
nearest  pathological  laboratory  for  examination.  The  finding  of 
the  Negri  bodies  in  the  large  ganglion  cells  of  the  hippocampus 
major,  the  cortex,  or  elsewhere  is  positive.  Portions  of  the  brain 
and  cord,  or  a  small  amount  of  saliva,  inoculated  into  the  meninges 
of  rabbits,  cause  characteristic  lesions.  This  may  be  done  when 
for  any  reason  the  brain  examination  is  not  satisfactory. 

The  incubation  period  is  usually  about  si^  weeks.  Rarely,  the 
disease  appears  a  few  days,  rarely  a  year,  after  the  infection.  The 
wound  may  heal  nicely.  At  the  end  of  the  incubation  period,  the 
wound  or  its  scar  becomes  inflamed  and  painful,  and  may  sup- 
purate. The  patient  becomes  anxious  and  irritable  and  the  tension 
of  the  laryngeal  and  pharyngeal  muscles  causes  dyspnea,  dys- 
phagia and  hoarseness  or  dysphonia.  About  a  day  after  the  begin- 
ning of  these  symptoms,  the  second  or  stage  of  excitement  begins. 
Hyperesthesia  is  marked;  a  slight  sound,  especially  of  running 
water,  a  draft  of  cool  air,  or  a  ray  of  light  may  precipitate  convul- 
sions. These  are  tonic,  rarely  clonic,  and  may  cause  death  from 
asphyxia.  The  dysphagia  and  hypersecretion  of  saliva  cause  froth- 
ing at  the  mouth.  The  convulsive  action  of  the  muscles  of  the 
jaws  may  cause  clicking  noises  and  the  hoarseness  of  the  voice, 
with  dysphonia,  may  suggest  barking  or  snapping,  but  attempts 
to  imitate  the  barking  or  manner  of  a  dog  prove  the  absence  of 
rabies,  and  suggest  hysteria  (lyssophobia,  pseudohydrophobia, 
q.  v.).  During  this  stage  the  temperature  may  be  normal  or  to 
103°  F.  The  pulse  is  irregular,  and  finally  the  spasms  appear 
spontaneously.  Suicidal  attempts  with  or  without  melancholia,  are 
frequent.  After  one  to  three  days  the  spasms  cease  gradually,  and 
the  third,  or  paralytic  stage  appears.  Unconsciousness  supervenes, 
the  heart  gradually  fails  and  death  follows  in  six  to  twenty  hours. 
Recovery  from  typical  rabies  has  never  been  reported. 

Treatment.  Prompt  and  thorough  cauterization  of  the  wound 
with  caustic  potash  or  actual  cautery  is  indicated.  The  Pasteur 
treatment  must  be  begun  early  if  at  all.  The  patient  should  be 
sent  to  the  nearest  institute  for  treatment  if  this  is  to  be  given. 


532  DISEASES  PROM  ANIMALS 

The  wound  should  be  kept  open  and  drained  for  six  weeks.  After 
the  disease  appears  darkness  and  quiet  are  necessary.  Chloroform 
is  needed  for  the  spasms.  The  absolutely  fatal  prognosis,  after 
the  disease  has  manifested  itself,  should  indicate  the  free  use  of 
every  method  possible  to  relieve  the  suffering.  No  cases  are 
reported  in  osteopathic  literature. 

Prophylaxis.  Dogs  harbor  and  transmit  several  dangerous 
infections,  besides  rabies,  and  their  existence  should  be  permitted 
only  under  strict  supervision.  In  country  places,  healthy  dogs 
may  be  useful.  Sick  dogs  are  always  dangerous,  especially  to 
children.  There  is  no  room  for  dogs  in  crowded  places,  and  the 
sooner  the  sentimental  petting  of  dogs  is  superseded  by  a  saner 
sentiment  in  favor  of  cleanliness,  the  better  iov  the  human  race. 
Squirrels,  rats,  and  other  rodents  may  have  the  disease  in  a  mild 
form,  and  may  transmit  it  to  human  beings  or  to  dogs  in  the 
severe  form.  Nothing  but  the  total  extermination  of  these  animals, 
especially  in  cities,  should  be  considered. 

The  few  dogs  that  are  allowed  to  live  should  be  muzzled  when 
in  cities  or  in  the  presence  of  strangers.  Ownerless  dogs  should  be 
humanely  killed;  in  suspicious  cases  they  should  be  kept  under 
observation  a  few  weeks  before  death. 


TETANUS 

(Lock-jaw;  trismus;  cephalic  tetanus) 
Tetanus  is  a  specific,  infectious  disease,  caused  by  the  bacillus 
tetani  and  characterized  by  severe,  persistent  tonic  spasms  of  the 
muscles,  especially  those  of  the  jaw. 

Etiology.  The  exciting  cause  is  the  bacillus  tetani  of  Nicolaicr, 
which  usually  gains  entrance  to  the  system  through  some  small 
wound,  especially  a  puncture  wound,  and  produces  a  toxalbumin 
of  extraordinary  virulence  which  travels  to  the  central  nervous  sys- 
tem along  the  motor  nerves.  The  bacillus  multiplies  in  the  intes- 
tinal tract  of  the  horse  and  retains  vitality  in  the  soil  for  many 
years. 

The  forms  depend  upon  how  affected  and  the  part  affected. 

Idiopathic  tetanus  occurs  when  no  open  wound  is  discoverable. 

Traumatic  tetanus  occurs  when  an  open  wound  is  found. 

Tetanus  neonatorum  attacks  newborn  infants. 

Lock-jaw  or  trismus  affects  the  jaw  alone. 

In  Cephalic  tetanus  the  throat  and  face  are  affected. 

Diagnosis.  The  onset  is  sudden  with  stiffness  of  the  neck, 
tongue,  and  jaw.     There  are  headache,  gastric  disturbance,  and 


TETANUS  533 

languor.  Opening  the  mouth  and  deglutition  become  difficult  but 
not  painful ;  the  stiffness  increases,  extending  to  the  spinal  muscles, 
abdomen,  and  legs,  which  are  finally  held  in  a  firm  spasm.  Ortho- 
tonos,  opisthotonos,  pleurothotonos,  or  emprosthotonos  have  oc- 
curred. The  symptoms  vary  in  degree  and  severity.  The  jaw  may 
be  firmly  locked  or  may  yield  to  forced  extension.  (Lock-jaw  or 
trismus.)  The  muscles  of  the  face  may  be  involved  so  that  the 
angle  of  the  mouth  is  drawn  out  and  the  eyebrows  are  raised  (risus 
sardonicus).  Spasm  of  the  pharynx  and  esophagus  may  occur, 
especially  if  there  are  injuries  to  the  fifth  cranial  nerve. 

Associated  with  these  tonic  convulsions  is  intense  pain,  espe- 
cially if  the  chest  muscles  are  involved.  The  paroxysm  may  be 
excited  by  any  slight  sensory  impression,  as  a  draught  of  air  or 
the  slamming  of  a  door.  The  tension  may  be  relieved  so  that  the 
patient  is  able  to  walk  around  but  relaxation  is  never  complete 
and  the  patient  walks  as  if  his  legs  were  wooden.  The  spasms 
vary  in  frequency  from  a  few  minutes  to  several  hours  apart, 
ceasing  during  sleep. 

The  fever  is  slight,  or  to  110"  to  112"  F.  just  before  death;  the 
pulse  is  small  and  frequent  during  a  paroxysm;  perspiration  is 
excessive;  the  bowels  are  constipated  and  the  urine  is  febrile. 
The  mind  is  clear  throughout. 

Death  usually  occurs  within  four  days  from  exhaustion.  Chronic 
tetanus  presents  similar  symptoms  but  less  marked  and  develops 
more  slowly. 

The  toxin  appears  to  be  excreted  by  the  kidneys. 

The  exudate  from  the  initial  wound  contains  many  bacilli. 

Treatment.  Free  incision  and  thorough  disinfection  and  cau- 
terization of  the  wound  is  absolutely  necessary  and  the  wound 
must  be  kept  open  until  the  base  heals.  The  patient  is  put  into 
a  quiet,  darkened  room  with  all  sources  of  irritation  excluded. 
Strong,  thorough  treatment  of  the  cervical  region  is  indicated. 
Deep,  steady  pressure  of  the  nerve  centers  controlling  the  affected 
muscles  will  shorten  the  spasm.  The  hot  or  continuous  neutral 
bath  may  be  used.    All  the  excretory  organs  should  be  kept  active. 

Liquid  food  only  can  be  given.  It  may  be  necessary  to  resort 
to  rectal  or  nasal  feeding  if  the  spasms  are  too  much  localized. 

Anti-tetanic  serum  is  on  the  market,  but  its  use  should  not  be 
attempted  by  the  general  practitioner.  If  it  should  be  decided,  in 
any  case,  to  employ  this  method,  only  someone  who  has  made 
especially  careful  study  is  able  to  secure  the  maximum  of  good 
with  the  minimum  of  danger. 

Prognosis.  The  mortality  in  traumatic  cases  is  80%,  in  idio- 
pathic, 50%.  Fatal  cases  usually  die  within  6  days.  Favorable 
features  are:  childhood,  slight  fever,  localized  spasms,  and  longer 
incubation  period. 


534  DISEASES  FROM  ANIMALS 

Prophylaxis.  Every  wound,  especially  of  a  puncture  character, 
should  be  immediately  cleansed  and  antiseptically  dressed.  Those 
inflicted  around  stables  or  from  rusty  nails  must  be  opened  thor- 
oughly and  kept  open  until  all  danger  is  past. 

The  increased  use  of  automobiles  instead  of  horses  is  an  impor- 
tant factor  in  lowering  the  death  rate  from  tetanus. 

FOOT  AND  MOUTH  DISEASE 

(Epidemic  stomatitis;  aphthous  fever) 
Foot  and  mouth  disease  is  an  acute,  specific,  infectious  disease 
of  cattle,  sheep  and  pigs,  which  may  be  communicated  to  man  by 
the  ingestion  of  dairy  products  from  diseased  cattle  or  by  direct 
inoculation;  characterized  by  a  vesicular  eruption  of  the  mem- 
branes of  the  mouth  and  by  constitutional  symptoms.  The  exciting 
cause  is  unknown.  The  incubation  period  is  from  three  to  five 
days. 

Diagnosis.  The  onset  is  marked  by  chilliness  and  fever,  digest- 
ive disturbances,  salivation  and  the  appearance  of  a  vesicular  erup- 
tion upon  the  lips,  inside  of  the  cheeks,  and  the  pharynx.  In 
children,  a  miliary  or  pustular  eruption  appears  upon  the  skin, 
especially  of  the  hands. 

In  severe  cases,  hemorrhages  may  occur.  The  duration  is  about 
a  week. 

Treatment.  The  treatment  is  that  of  stomatitis.  Recovery  is 
to  be  expected  in  a  few  days  to  a  few  weeks,  according  to  the 
sanitary  conditions. 

Prophylaxis.  Isolation  of  human  patients  and  diseased  cattle 
and  quarantine  of  their  attendants  are  important.  During  an  epi- 
demic, all  milk  should  be  boiled  before  being  used. 

ACTINOMYCOSIS 

Actinomycosis  is  a  chronic  infectious  disease  occurring  among 
cattle  and  pigs  and  affecting  man,  due  to  the  presence  and  multi- 
plication of  the  streptothrix  actinomyces.  The  fungus  is  common 
on  various  grains  as  oats,  barley,  etc.  It  may  be  taken  in  with 
the  food  or  be  inhaled  with  dust  from  grain. 

In  animals  it  causes  the  disease  known  as  "lumpy  jaw."  In 
man,  it  is  most  liable  to  attack  the  lungs,  intestines,  or  liver,  as 
well  as  the  jaw  and  neck,  but  any  organ  may  be  involved.  The 
skin  is  sometimes  affected. 

It  leads  to  great  connective  tissue  proliferation  with  the  forma- 
tion of  nodular  masses  which  may  be  mistaken  for  osteosarcoma. 
Ultimately,  suppuration  takes  place  and  deep-seated  abscesses  are 
the  result. 


ACTINOMYCOSIS  535 

Diagnosis.  The  g^eneral  features  are  irregular  fever,  depending 
largely  upon  the  existence  of  suppuration  and  the  location  of  the 
lesion. 

Lumpy  Jaw.  There  may  be  swelling  of  one  side  of  the  face,  or 
enlargement  of  the  jaw.  The  tongue  may  be  involved,  showing 
small  nodular  growths  either  primary  or  secondary  to  those  of  the 
jaw.    An  abscess  forms  which  discharges  the  fungus  in  the  pus. 

Intestinal  Actinomycosis.  The  symptoms  are  gastric  disturb- 
ances, diarrhea,  and  localized  pain  or  tenderness,  with  symptoms  of 
pericecal  abscess  or  appendicitis,  perforative  peritonitis,  or  hepatic 
abscess. 

Pulmonary  Actinomycosis  is  characterized  by  cough,  fever, 
wasting,  and  a  mucopurulent  or  fetid  expectoration  often  contain- 
ing the  fungus.  Irregular  fever  and  offensive  sputum,  the  physical 
signs  of  consolidation  especially  in  the  mammillary  and  axillary 
region  and  in  the  middle  zone  of  the  thorax  may  suggest  tuber- 
culosis. Actinomycotic  abscesses  form  large  cavities  which  may 
be  diagnosed  in  life. 

Lesions  of  other  organs  may  be  present  with  the  pulmonary 
form  as  erosion  of  the  vertebrae,  necrosis  of  the  ribs  and  sternum 
with  nodular  formation,  subcutaneous  abscesses  and  metastasis. 

Cutaneous  Actinomycosis  is  marked  by  a  chronic  ulceration 
resembling  skin  tuberculosis,  with  tumor  growths  which  suppurate 
and  leave  open  sores  which  may  remain  for  years. 

Cerebral  Actinomycosis  has  the  symptoms  of  brain  tumor  or 
abscess.  The  fungus  may  be  found  in  the  urine  when  the  disease 
exists  in  the  genito-urinary  tract. 

In  the  sputum,  the  fungus  and  small  "sulphur"  granules  or 
thread-like  particles  of  yellow  color  are  found.  Elastic  fiber  from 
the  lung  is  never  found.  Pus  containing  the  fungus  may  be  dis- 
charged with  the  buccal  secretion.  The  disease  may  affect  the 
tonsil. 

Treatment.  Very  little  can  be  done  after  the  disease  has 
become  established.  Surgical  evacuation  of  the  pus  when  the 
abscess  is  localized  and  accessible,  gives  a  fairly  good  prognosis. 
The  treatment  for  pulmonary  tuberculosis  should  be  used  in  the 
pulmonary  form.  Sometimes  the  process  may  be  kept  very  slow, 
and  fairly  comfortable  existence  prolonged  for  years. 

Complete  recovery  is  rare. 

Prophylaxis.  Persons  caring  for  cattle  should  be  very  careful 
when  they  find  one  with  "lumpy  jaw"  to  see  that  it  is  treated  and 
cured  or  else  killed  and  the  body  deeply  buried.  When  handling 
animals  with  this  disease,  they  should  use  the  utmost  cleanliness. 
Chewing  straws  should  be  forbidden. 


536  DISEASES  FROM  ANIMALS 

MILK  SICKNESS 

(Trembles) 

Milk  sickness  is  an  infectious  disease  of  cattle  (trembles)  com- 
municable to  man  by  the  ingestion  of  the  milk  or  flesh  from  the 
diseased  animal,  occurring  in  the  new  settlements  of  the  Western 
states,  and  characterized  by  constitutional  symptoms  and  a  swollen 
and  tremulous  tongue. 

Diagnosis.  Prodromal  malaise,  headache,  and  anorexia  are 
present.  In  a  few  days,  a  burning  pain  in  the  stomach,  nausea, 
vomiting,  excessive  thirst,  and  obstinate  constipation  occur.  The 
breath  has  a  characteristic  foul  odor.  The  tongue  is  swollen  and 
tremulous.  In  severe  cases,  there  is  restlessness,  hebetude,  coma 
or  convulsions,  with  development  of  the  typhoid  state  and  ulti- 
mately a  fatal  result.  Slight  fever  is  usually  present  but  may  be 
absent.  The  duration  is  from  three  days  to  three  or  four  weeks, 
averaging  ten  days. 

Treatment.  Full  washings  of  the  colon ;  the  usual  treatment  for 
fever,  and  other  symptomatic  treatment  are  indicated. 

Prognosis.  Recovery  is  the  rule  but  in  grave  acute  cases  death 
may  occur  in  three  days. 

Prophylaxis.  Cattle  with  trembles  should  be  killed  and  the 
body  buried  or  burned.  The  milk  from  the  rest  of  the  herd  must 
be  boiled,  if  used.  Carefulness  in  caring  for  the  sick  animals,  espe- 
cially in  thoroughly  cleansing  the  hands,  is  necessary. 

GLANDERS 

(Farcy;  malleus  humidus;  equinia) 

Glanders  is  an  acute  infectious  disease,  occurring  in  horses,  due 
to  the  bacillus  mallei,  and  characterized  by  the  formation  of  gran- 
ulation-tissue nodules  in  the  nostrils  (glanders),  or  under  the 
skin  (farcy)  ;  sometimes  occurring  as  an  industrial  disease  in  man, 
especially  among  grooms  and  stable-boys,  and  those  caring  for 
horses.  It  is  caused  by  the  discharges  from  an  infected  animal 
reaching  an  abrasion  or  a  mucous  surface.  The  incubation  period 
is  from  three  to  five  days. 

Acute  Glanders.  There  is  redness  and  swelling  of  the  nasal 
mucous  membrane  with  burning  and  dryness,  followed  by  the 
development  of  nodules  which  rapidly  break  down  and  discharge 
a  fetid  hemorrhagic  or  mucopus.  Headache,  painful  deglutition, 
cough,  fever,  and  prostration  are  later  followed  by  the  typhoid 
state  and  eventually  terminate  in  death. 

Twelve  or  fourteen  days  after  the  disease  begins  lumps  arise 
just  under  the  skin  or  in  the  muscles,  and  necrosing,  discharge  a 
bloody  fluid  containing  the  bacillus  mallei. 


ANTHRAX  537 

Acute  Farcy  (glanders  of  the  skin).  The  site  of  inoculation 
becomes  inflamed,  swollen  and  red.  Neighboring  inflamed  lym- 
phatics appear  as  small  nodules,  "farcy-buds."  The  constitutional 
disturbances  include  rigors  and  sharp  fever,  A  local  or  general 
eruption  appears ;  abscesses  develop  in  the  subcutaneous  tissue,  and 
muscles;  the  joints  may  suppurate  and  the  internal  organs  become 
involved.  This  grave  pyemia  leads  to  death  in  the  course  of  one 
to  three  weeks. 

Chronic  Glanders  (or  farcy).  This  form  is  characterized  by 
the  development  of  a  local  granuloma,  which  breaks  down  into  an 
irregular  ulcer  with  thickened  edges  and  a  foul  discharge.  The 
lymphatics  also  tend  to  ulcerate  and  the  nasal  mucosa  may  become 
afifected.  The  disease  may  last  for  years  but  may  take  fatal,  acute 
form  at  any  time. 

The  diagnosis  is  difficult.  It  may  be  made  by  cultures  from 
the  discharge;  by  agglutination  test,  or  by  injection  of  some  of  the 
discharge  into  the  peritoneal  cavity  of  a  guinea-pig: 

Treatment.  The  indications  are  surgical  attention,  cleanliness 
L»f  the  nasal  passages,  and  nutritious  diet. 

Prognosis."  The  acute  form  is  fatal.  The  chronic  form  may 
recover  with  proper  treatment. 

Prophylaxis.  Diseased  horses  should  be  killed  and  their  bodies 
buried  or  burned,  their  stalls  torn  down,  purified  and  entirely  re- 
built.   The  use  of  mallein  is  used  to  detect  glanders  in  animals. 

ANTHRAX 

(Charbon;    malignant    pustule;    wool-sorter's    disease;    splenic    fever;    splenic 

apoplexy) 

Anthrax  is  an  acute  specific  infection  due  to  the  bacillus  anthra- 
cis,  essentially  a  disease  of  cattle  and  sheep  but  attacking  man 
chiefly  as  an  industrial  disease,  and  characterized  by  a  local  or 
general  type. 

Butchers,  tanners,  wool-sorters,  hair-combers,  sometimes  vet- 
erinary surgeons,  and  those  who  work  in  hides  or  who  care 
for  cattle  and  sheep  are  liable  to  infection.  The  bacilli  may  also 
be  carried  by  flies. 

The  incubation  period  is  one  to  six  days.  The  mode  of  infec- 
tion in  man  is  through  a  wound  or  scratch  on  the  skin,  by  the 
respiratory  tract,  or  by  the  alimentary  tract.  The  local  form  is 
found  in  two  varieties,  the  malignant  pustule  and  anthrax  edema. 
The  general  form  is  named  according  to  the  organ  attacked. 

Malignant  Pustule  is  due  to  skin  inoculation,  and  occurs  on 
exposed  parts  as  the  face,  hands,  neck,  and  lips.     It  begins  with 


538  DISEASES  FROM  ANIMALS 

prickling  and  burning,  a  small  papule  forms,  becomes  vesicular 
and  surrounded  by  a  dusky  red  indurated  areola.  The  fluid  of 
the  vesicle  passes  quickly  from  clear  to  bloody  and  escapes,  form- 
ing a  dark  scab  at  the  summit.  There  may  be  a  ring  of  vesicles 
around  this  eschar.  It  may  then  disappear  or  may  extend,  pro- 
ducing great  induration  and  brawny  edema.  The  lymphatic  glands 
are  swollen  but  there  is  little  or  no  pain  or  distress,  even  when  the 
case  is  severe.  Prostration,  sweats,  splenic  enlargement  and  other 
systemic  disturbances  may  appear.  The  temperature  is  at  first 
high  but  may  afterwards  be  normal.  Death  may  occur  in  three 
to  five  days  or  a  slow  recovery  follow  upon  sloughing  out  of  the 
eschar. 

Anthrax  Edema.  The  eschar  and  induration  are  absent,  the 
constitutional  symptoms  are  very  grave;  swelling  is  an  extensive 
and  spreading  edema,  beginning  usually  around  the  eyes.  It  is  a 
pale  red  or  yellowish  swelling  which  may  go  on  to  gangrene.  This 
form  is  much  more  fatal  than  the  malignant  pustule,  the  mortality 
being  about  33%.    The  general  form  .is  rare  in  man. 

Respiratory  Anthrax  (wool-sorter's  disease).  The  primary 
lesion  is  usually  in  the  trachea  and  the  larger  bronchi  where  there 
are  patches  of  intense  swelling  of  the  mucous  membrane  with 
hemorrhages  and  ulcerations.  Broncho-pneumonia,  enlarged  spleen 
and  mediastinal  glands  are  frequent.  The  disease  begins  with 
chill,  fever  to  103°  F.,  headache,  vomiting  or  diarrhea,  and  marked 
prostration.  There  are  varying  pulmonary  symptoms — hurried 
breathing,  great  pain  in  the  chest,  and  cyanosis.  Delirium  is  com- 
mon. Death  usually  occurs  in  three  or  four  days.  If  the  patient 
survives  a  week  recovery  may  be  expected; 

Gastro-Intestinal  Anthrax  (mycosia  intestinalis)  gives  rise  to 
hemorrhagic  lesions  of  the  mucous  membrane  of  the  intestines, 
with  enlarged  mesenteric  glands  and  spleen.  Suggilations  appear 
on  the  gums.  There  are  symptoms  of  an  intense  poisoning — severe 
vomiting  and  diarrhea  with  possibly  blood-streaked  stools,  and 
tumid  abdomen.  The  pyrexia  is  slight  and  death  is  preceded  by 
intense  collapse  !n  one  to  seven  days.  The  bacillus  anthracis  is 
found  in  the  blood,  pus,  exudate,  serum,  sputum,  and  elsewhere. 

Treatment.  The  treatment  is  mainly  surgical.  The  local  lesion 
should  be  destroyed  by  caustic  potash  or  the  actual  cautery ;  the 
swelling  should  be  excised,  if  not  too  large.  If  large,  crucial 
incisions  are  made  and  the  parts  cauterized  with  pure  carbolic 
acid.  The  carbolic  lotion  should  be  injected  into  the  surrounding 
tissues  two  to  three  times  a  day.  The  diet  and  other  treatment 
depends  upon  the  condition  of  each  patient  as  found  on  examina- 
tion. « 


ANTHRAX  539 

Prognosis.  If  the  pustule  is  promptly  operated,  recovery  is  the 
rule.    Internal  anthrax  is  usually  fatal. 

Prophylaxis.  Prevent  anthrax  in  animals  by  preventing  the 
spread  of  infected  material.  Burn  the  bodies  of  dead  infected 
animals  unopened  and  under  the  supervision  of  the  sanitary  author- 
ities. Those  who  w^ork  with  animals  should  be  taught  the  dangers 
of  uncleanliness,  and  every  provision  made  for  their  personal 
hygiene. 

OTHER  DISEASES 

Nearly  all  the  worms  that  infest  the  human  body  are  the  gift 
of  animals  to  mankind.  Tapeworms,  trichina  and  others  are  taken 
into  the  human  body  with  raw  or  improperly  cooked  meat  or  fish. 
Sheep  or  rabbits  distribute  the  microscopic  eggs  of  flukes  or  coc- 
cidia  in  water  or  over  vegetables,  with  fecal  material.  People  who 
drink  the  water  or  eat  the  vegetables  without  cooking,  become  the 
hosts  of  these  worms.  Horses,  cats  and  dogs  carry  round  worms, 
and  other  worms,  very  plentifully.  The  microscopic  eggs  of  these 
worms  are  scattered  around  with  fecal  material  and  also  with  the 
dust  and  hairs  which  have  been  contaminated  with  fecal  material. 
By  unwashed  hands  and  in  other  ways,  and  by  flies,  the  fecal 
material  bearing  the  eggs  reaches  human  food,  and  the  eggs  de- 
velop in  human  bodies. 

Other  less  common  diseases  are  splenomegaly  and  Leishman- 
iasis, derived  from  dogs,  camels,  and  rats,  probably  by  the  way 
of  fleas;  and  Malta  fever,  given  by  the  goat  in  infected  milk. 

Domestic  animals,  as  well  as  mosquitoes,  flies,  rats,  and  other 
insects  carry  infection  from  place  to  place  with  celerity. 


CHAPTER  XLIX 
DISEASES  DUE  TO  AGENTS  YET  UNKNOWN 

VARIOLA 

(Smallpox) 

Variola  is  an  acute,  specific,  infectious,  highly  contagious,  epi- 
demic disease,  characterized  by  lumbo-sacral  pains,  vomiting,  an 
initial  fever  lasting  from  three  to  five  days  followed  by  character- 
istic eruption.  The  maturation  of  the  pustular  stage  is  accom- 
panied by  a  secondary  fever  during  the  presence  of  which  grave 
complications  are  prone  to  occur.  The  secondary  fever  may  not 
appear. 

Etiology.  The  disease  is  caused  by  one  or  more  specific  agents 
whose  nature  is  unknown  but  which  retain  virulence  for  a  long 
time.  There  is  no  period  of  the  disease  after  invasion  when  it  is  not 
contagious  although  it  is  most  virulent  during  the  suppurative 
period.  It  is  spread  by  fomites,  contact  with  the  pustular  con- 
tents, scabs  or  scales  of  desquamating  skin.  Unlike  most  ery- 
thematous diseases,  it  attacks  all  ages,  classes  and  conditions  of 
life. 

Smallpox  attacks  those  who  are  apparently  of  robust  physique, 
though  doubtless  lowered  vitality  is  one  factor  in  predisposing  to 
the  disease.  It  is  especially  those  who  are  most  robust  who  are 
most  frequently  exposed  to  the  infection.  It  is  also  true  that  a 
robust  and  florid  appearance  by  no  means  denotes  heightened 
vitality.  Moderate  drinkers,  so-called,  have  often  this  florid  appear- 
ance, and  they  are  especially  subject  to  infection  from  smallpox. 
They  usually  suflfer  the  disease  in  more  virulent  form  than  do  non- 
drinkers.     (Dne  attack  usually  confers  immunity. 

The  incubation  period  is  from  eight  to  sixteen  days,  not  often 
attended  by  recognizable  symptoms.  The  predisposing  factors 
are :  debility  from  illness  or  poor  nourishment,  alcoholism,  unhy- 
gienic surroundings,  muscular  lesions  of  the  occipito-atlantal  and 
atlanto-axoidal  articulations  and  such  other  contractions  of  the 
neck  muscles  as  narrow  the  thoracic  inlet,  or  interfere  with 
metabolism  in  any  of  its  phases.  Fear  must  also  be  mentioned  as 
a  cause. 

Pathologjy.  Granular  and  fatty  degeneration  occurs  in  the  liver, 
spleen,  kidneys,  and  heart.  Infiltration  is  found  in  the  adrenal  glands  and  the 
testicle.  During  the  papular  stage,  there  is  local  hyperemia  of  the  papillae, 
with  interstitial  exudation  and  colliquative  necrosis  of  rete  cells,  so  that  a 
vesicle  is  formed,  peculiar  in  that  it  is  tra^versed  by  delicate  bands  of  epithelial 
cells.    This,  with  the  fact  that  coagulation-necrosis  occurs  mainly  in  the  center, 

540 


VARIOLA  541 

gives  it  the  umbilicated  or  depressed  appearance.  The  contents  of  the  vesicle 
are  plasma,  fibrin,  and  cell  detritus.  Leucocytic  invasion  converts  vesicle  into 
pustule.  This  has  a  more  globular,  elevated  appearance  than  the  umbilicated 
vesicle.  Pyogenic  x)rganisms  are  found  in  the  pus.  Whe.i  the  inflammation 
injures  the  corium,  scars  are  apt  to  result;  this  occurs  when  the  skin  is  scratched. 
The  actinic  light  rays  increase  this  danger. 

Diagnosis.  The  stage  of  invasion  lasts  about  three  days.  It  is 
characterized  by  sudden  onset  with  violent  chills  and  shivering, 
agonizing  pains  in  the  back  and  legs ;  intense  headache  mostly 
frontal,  a  temperature  rapidly  reaching  102°  to  104°  F.,  full, 
strong  and  rapid  pulse,  100  to  140,  uncontrollable  vomiting,  phar- 
yngitis, face  red,  eyes  bright,  coated  tongue,  anorexia,  constipation, 
sleeplessness,  delirium,  often  copious  perspiration,  and  extreme 
prostration.  An  "initial  exanthem"  clearing  within  24  to  48  hours 
appears.  It  is  either  hemorrhagic  or  erythematous.  About  the 
third  day,  the  true  eruption  makes  its  appearance,  first  upon  the 
forehead  and  in  the  scalp,  then  the  rest  of  the  face,  the  backs  of 
wrists,  trunk,  arms,  and  lastly  the  legs,  most  abundant  upon  parts 
exposed  to  the  atmosphere.  With  the  appearance  of  the  eruption 
all  symptoms  abate,  the  temperature  falls,  and  the  patient  may  feel 
quite  comfortable.  The  eruption  consists  of  coarse,  red  spots  upon 
the  body,  like  flea-bites,  rapidly  becoming  within  twenty-four  hours 
slightly  raised  red  papules,  feeling  hard  and  shotty  to  the  touch, 
and  each  surrounded  by  a  broad  red  inflammatory  band,  the  areola. 
Usually  by  the  sixth  day  the  papules  become  converted  into  umbili- 
cated vesicles,  at  first  clear,  then  turbid.  They  are  hard  and 
indurated  to  the  touch,  and  on  the  eighth  or  ninth  day  they 
become  pustular.  The  areola  becomes  much  darker,  and  the  tem- 
perature rises  to  103°  to  105°  F.,  pulse  110  to  120.  The  other 
symptoms  all  reappear  with  salivation  and  delirium.  Marked 
edema  of  the  skin  renders  the  face  unrecognizable.  The  pustules 
are  painful,  especially  in  places  where  the  skin  is  thickened.  The 
maturation  lasts  about  three  days,  when  the  fever  falls  by  lysis. 
If  fatal,  death  usually  takes  place  about  the  tenth  day,  preceded  by 
feeble  and  more  rapid  pulse,  marked  delirium,  subsultus,  and  some- 
times diarrhea.  About  the  eleventh  day,  dessication  begins,  the 
pustules  begin  to  dry,  forming  dark  scabs  which  are  tightly  adher- 
ent. The  fever  and  other  symptoms  subside  but  itching  becomes 
annoying.  The  odor  from  the  pustular  stage  on  is  a  peculiar  greasy 
one. 

After  the  rupture  of  large  pustules  the  centers  frequently  dry 
and  sink  in,  often  in  the  shape  of  a  Maltese  'cross.  This  is  most 
typically  seen  upon  the  backs  of  the  hands  and  is  pathognomonic. 
Toward  the  end  of  the  third  week  the  scabs  fall,  leaving  red  glis- 
tening pits  which  disappear  or  change  into  deep  white  striated 
scars.    The  hair  falls  but  may  grow  again. 


542  DISEASES  DU^  TO  UNKNOWN  AGENTS 

Secondary  toxic  or  septic  rashes  appear  during  the  stage  of 
decrustation,  sometimes  with  mild  fever.  They  may  be  either 
scarlatiniform,  morbilliform  or  hemorrhagic.  The  skin  immediately 
surrounding  the  drying  pocks  is  often  exempt,  leaving  an  anemic 
halo.  This  rash  lasts  about  three  days,  and  fades  or  desquamates. 
With  the  development  of  the  skin  eruption,  an  exanthem  appears 
upon  the  mucous  membranes  of  the  body  cavities,  developing  into 
ulcers.  This  may  develop  before  the  dermal  rash  and  be  of  diag- 
nostic importance. 

VARIETIES 
Variola  Vera  is  the  discrete  form  in  which  symptoms  are  of 
moderate  severity  and  the  pocks  are  separated  by  healthy  skin. 

Variola  Confluens  is  characterized  by  the  early  appearance  of 
the  eruption,  the  coalescence  of  the  pustules,  marked  prostration, 
noisy  delirium,  stupor,  high,  irregular  secondary  fever,  profuse 
salivation,  and  sometimes  uncontrollable  vomiting  and  diarrhea. 
Death  is  apt  to  occur  about  the  tenth  day.  If  recovery  occurs, 
convalescence  is  tedious  and  disfiguring  scars  are  common  in  the 
most  favorable  cases. 

Abortive  Type.  The  prodromal  phenomena  are  mild.  The 
eruption  either  fails  to  appear  by  the  fourth  day  or  only  a  few 
pocks  go  through  the  regular  metamorphosis,  or  the  development 
of  the  pocks  ceases  in  the  papular  stage. 

Malignant  Smallpox.    Of  this  there  are  three  forms. 

Variola  Pustulosa  Hemorrhagica  (black  smallpox)  is  charac- 
terized by  hemorrhages  into  the  pocks  and  upon  the  mucous  mem- 
branes of  the  entire  body.  '  Collapse,  cardiac  weakness  and  death 
are  usual.  The  mind  remains  clear  and  the  patient  is  conscious  of 
his  danger. 

Purpura  Variolosa  (variola  purpurica).  On  first  or  second 
day  the  prodromal  exantheni  rapidly  becomes  hemorrhagic  and 
does  not  disappear  upon  pressure  with  the  finger.  Severe  angina, 
hemorrhages  from  the  gums,  lungs,  stomach,  uterus,  bowels,  and 
urinary  tract  follow.  Death  occurs  about  the  fourth  day,  pre- 
ceded by  signs  of  collapse,  which  has  manifested  itself  by  a  rela- 
tively low  temperature  even  before  the  pustule  appeared.  Some 
few  hemorrhagic  pocks  occasionally  appear.  The  diagnosis  of 
the  condition  is  by  history  of  exposure  to  smallpox  and  the  char- 
acteristic prodromes. 

Corymbose  Variola  is  a  rare  but  severe  form  in  which  the 
pocks  are  arranged  in  grape-like  clusters. 

Varioloid  (modified  or  mitigated  smallpox;  variola  benigna; 
variola  modificata).    Persons  exposed  to  smallpox  .sometimes  suf- 


VARIOLA  543 

fer  from  varioloid  instead.  Persons  who  have  had  smallpox  may- 
suffer  from  varioloid  at  subsequent  exposure  to  smallpox.  Vaccina- 
tion appears  to  initiate  an  attack,  in  persons  peculiarly  susceptible, 
or  as  the  result  of  improperly  performed  vaccination.  The  lesions 
remain  in  the  epidermis,  the  course  of  the  eruption  is  shorter,  the 
papules  vesicate  by  the  fifth  day,  the  process  of  suppuration  is 
abridged,  decrustation  occurs  rapidly  with  little  or  no  scarring, 
and  all  symptoms  are  milder.    There  are  various  modifications. 

Variola  sine  Exanthemate  or  variola  sine  variolis  has  the  usual 
symptoms  but  no  eruption  or  a  very  few  pocks. 

Variola  Verrucosa.  The  large  solid  conical  papules  with  small 
vesicles  at  their  apices  rapidly  desiccate  and  form  crusts  and  finally 
disappear  without  scars.  Variola  miliaris  has  very  small  yellowish 
vesicles. 

Variola  Cornea  (horn-pox)  is  known  by  the  hard  mahogany 
crusts. 

Complications.  During  the  secondary  fever,  there  may  be 
broncho-pneumonia,  pleurisy,  dysentery;  hemorrhages  of  all 
kinds,  ulcerative  eye,  ear,  and  laryngeal  conditions,  purulent  arthri- 
tis, orchitis,  gangrene  when  the  swelling  is  great  and  subcutaneous 
abscesses  form,  often  attacking  the  penis  and  scrotum;  erysipelas 
attacking  the  face,  and  rarely  nephritis.  During  convalescence, 
carbuncles,  boils  and  other  subcutaneous  abscesses  are  very  com- 
mon. Disturbances  of  the  peripheral  nervous  system  as  neuritis, 
peripheral  paralyses  especially  of  the  palatal  muscles,  neuro-retini- 
tis,  and  otitis  media  are  less  common.  The  sequelae  most  com- 
mon are  boils  and  abscesses,  deep  pitting,  otitis  media,  blindness, 
and  permanent  baldness. 

The  urine  has  the  usual  febrile  changes.  The  white  blood  cells 
reach  10,000  to  20,000  or  more.  Lymphocytosis  occurs  during 
pustulation;  the  polymorphonuclear  cells  are  decreased  to  40%, 
sometimes  12% ;  myelocytes  and  irritation  forms  are  found.  Dur- 
ing the  febrile  stage,  there  is  a  polycythemia  followed  by  an 
anemia  to  3,000,000  or  less  during  the  pustular  stage.  Regenera- 
tion is  slow,  lasting  about  fourteen  days.  Normoblasts  are  rare 
except  in  the  hemorrhagic  forms.  Exudate  taken  from  the  pustule 
shows  streptococci,  staphylococci,  and  pseudodiphtheria  bacilli. 

Smallpox  may  be  confused  with  a  long  list  of  diseases,  includ- 
ing varicella,  measles,  cerebro-spinal  meningitis,  scarlet  fever, 
pneumonia,  syphilis,  typhus  fever,  and  septico-pyemia. 

Treatment.  The  imperative  demands  of  treatment  are  isola- 
tion, ventilation,  cleanliness,  and  disinfection.  When  suspicious 
symptoms  of  smallpox  are  found,  the  proper  authorities  should  be 
notified  at  once  and  the  patient  isolated.  When  the  diagnosis  is 
made,  hair  and  beard  should  be  cut  very  close. 


544  DISEASES  DUE  TO  UNKNOWN  AGENTS       - 

The  room  should  be  well  ventilated,  the  windows  screened 
and  slightly  darkened  by  red  curtains  to  exclude  the  ultra-violet 
rays  of  light.  The  temperature  should  be  maintained  at  65°  F. 
All  superfluous  hangings,  rugs,  and  furniture  should  be  removed. 
The  doorways  may  be  protected  by  a  sheet  dampened  with  car- 
bolic solution  1 :60.  The  nurse  must  be  of  robust  physique,  pref- 
erably immune,  and  not  afraid.  Male  nurses  must  have  very  short 
hair  and  no  beard.  Female  nurses  must  have  short  hair  or  must 
wear  a  close  cap.  Absolute  cleanliness  is  secured  by  plenty  of 
baths,  clean  bed  and  personal  linen,  and  careful  nursing.  The 
physician  must  put  on  a  special  suit  with  cap  and  gloves  which 
he  keeps  in  the  house  but  not  in  the  sick  room. 

Remove  all  bony  and  muscular  lesions  found  and  pay  strict 
attention  to  the  lower  thoracic  soine  and  ribs.  No  adjustment 
requiring  difficult  and  painful  technique  is  to  be  g^ven  after  symp- 
toms make  their  appearance.  Reflex  muscular  contractions  must 
be  relieved  as  frequently  as  they  recur.  It  is  best  to  visit  him 
from  once  to  three  times  a  day,  treating  the  special  symptoms  as 
they  arise. 

"I  have  never  yet  seen  the  so-called  'fever  of  pustulation.'  In  every 
instance  the  fever  has  dropped  when  the  eruption  appeared,  and  has  not 
recurred.  This  is  probably  due  to  the  use  of  systemic  antiseptics  throughout 
the  entire  course  of  the  disease.  From  the  cases  which  I  have  had,  I  would 
say  that  osteopathic  manipulation  would  be  impossible.  The  eruptions  are  so 
numerous,  and  so  sore,  that  it  would  be  impossible  to  get  the  fingers  on  the 
flesh  anywhere  without  interfering  with  them.  The  onset  of  the  cases  of  small 
pox  that  have  come  under  my  observation,  has  been  very  much  like  typhoid 
fever,  the  slow  pulse,  step-ladder  temperature,  general  aching,  and  malaise." 
— G.  J.  Conley. 

Diet.  During  the  period  of  vomiting,  pellets  of  ice  in  the 
mouth  are  comfortable.  Later  barley  or  oatmeal  water  with  lemon 
juice  may  be  used.  Plenty  of  water  is  a  necessity.  As  the 
fever  declines  an  easily  digested  and  nutritious  diet  of  milk,  eggs, 
broths,  beef  juice  or  gruels  may  be  given  every  three  hours. 
During  convalescence,  a  full,  ,  well-regulated,  nutritious  diet 
should  be  ordered. 

The  daily  toilet  consists  in  keeping  the  skin  and  the  orifices 
of  the  body  clean  and  soft.  The  nose  is  cleansed  with  glycerine, 
cold  cream,  or  olive  oil,  which  also  keeps  the  crusts  soft.  The 
mouth  and  naso-pharynx  may  be  cleanse'd  with  Dobell's  solution, 
or  any  mild  antiseptic.  The  eyes  are  washed  with  warm  boric  acid 
solution  (gr.  v  to  xx  to  the  ounce),  sterile  water,  or  saline  solution. 
Cold  compresses  applied  over  the  eyelids  assist  in  reducing  the 
edema.  A  daily  tepid  sponge  is  necessar^^  Baths  may  be  given 
of  bichloride  of  mercury  (1:20,000)  or  creolin  (1:500).  These 
assist  in  cleanliness  and  also  aid  in  reducing  the  offensive  odor. 


VARIOLA  545 

Headache.  Deep,  steady  digital  pressure  in  the  suboccipital 
fossa  or  at  the  eighth  thoracic  spine,  the  ice  bag  to  the  head  or 
a  mustard  plaster  at  the  back  of  the  neck  may  relieve. 

Vomiting.  Thorough  relaxation  and  adjustment  in  the  great 
splanchnic  and  cervical  areas,  with  deep,  steady  digital  pressure  in 
the  occipital  triangles  or  at  the  fourth  and  fifth  dorsal  vertebrae 
on  the  right  side  will  usually  control  the  condition. 

Fever.  The  usual  fever  treatment  of  relaxing  through  the 
upper  dorsal  area,  correction  in  the  cervical  region  and  deep, 
steady  pressure  in  the  upper  cervical  area  are  good.  Warm  spong- 
ing in  lower  grades  of  fever,  the  bath  at  70°  F.,  and  the  cold  pack 
may  be  needed.  If  the  temperature  goes  very  high  give  a  con- 
tinuous cool  colonic  irrigation. 

In  confluent  cases,  the  prolonged  warm  bath  helps  guard 
against  septicemia,  the  pustules  become  softened  and  may  be 
evacuated  by  gentle  rubbing  with  gauze. 

Pitting.  Cold  wet  dressings  of  lint  soaked  in  any  comfortable, 
mildly  antiseptic  solution,  or  ice  water  and  glycerine,  are  to  be 
used  on  the  face  and  hands  to  prevent  pitting.  Hot  water  dress- 
ings are  more  comfortable  to  some  patients.  It  is  better  to  pro- 
tect the  skin  from  the  light,  especially  the  ultra-violet  rays.  This 
must  not  lead  to  any  lack  of  thorough  ventilation,  however.  When 
the  crusts  are  forming,  keep  them  moist  with  vaseline,  oil,  glyc- 
erine, or  carbolic  acid  in  lanolin  or  vaseline. 

Odor.  The  baths,  the  daily  toilet,  and  the  use  of  dusting  powder 
or  5%  iodoform  powder,  an  open  bottle  of  smelling  salts  or  of 
weak  ammonia,  all  are  fairly  good.    Plenty  of  fresh  air  is  bes.t  of  all. 

Cardiac  Weakness.  When  the  pulse  is  feeble  and  frequent,  a 
general  quieting  treatment  should  be  given,  including  relaxation 
of  the  cervical  areas  and  the  fourth  and  fifth  dorsal  segments.  An 
ice  bag  in  flannel  directly  over  the  heart  may  be  used. 

Diarrhea  in  children  may  be  relieved  by  deep,  steady  pressure 
over  the  second  lumbar  vertebra.    Enemas  are  useful. 

Maniacal  delirium  is  usually  prevented  by  spinal  extension, 
the  prolonged  warm  bath  and  the  cold  pack,  if  given  when  signs 
of  nervousness  appear.  Chloroform  or  morphia  may  be  required 
in  violent  or  suicidal  cases. 

Obstruction  of  the  Larynx,  This  usually  occurs  from  edema 
and  may  call  for  tracheotomy. 

Bed-sores.  If  the  patient  becomes  very  much  debilitated,  he 
may  become  subject  to  bed-sores  and  abscesses  even  under  the 
best  of  care.  Placing  him  upon  a  water-bed  or  in  a  continued  warm 
bath  is  indicated. 


546  DISEASES  DUE  TO  UNKNOWN  AGENTS 

Convalescence  is  not  to  be  considered  complete  until  the  skin 
is  perfectly  smooth  and  free  from  any  trace  of  a  crust. 

Prognosis.  The  prognosis  depends  upon  the  age  of  the  patient; 
complications;  and  the  environment  from  which  the  patient  comes, 
as  well  as  the  nursing.  In  varioloid  the  prognosis  is  recovery;  in 
the  discrete  variety,  good ;  in  the  confluent,  grave,  50%  die ;  in  the 
malignant  types,  all  perish.  In  those  under  five  years  and  over 
forty  the  prognosis  is  grave.  A  filthy  environment  predisposes  to 
complications.  Recurrences  seldom  occur;  a  second  attack  is 
usually  of  the  varioloid  type. 

Prophylaxis.  The  usual  rules  for  the  public  care  of  smallpox 
are :  rigid  isolation,  vaccination,  disinfection  of  the  skin  and  all 
fomites,  and  final  fumigation.  Quarantine  of  a  suspected  indi- 
vidual is  sixteen  days  after  exposure.  Isolation  is  continued  until 
the  disappearance  of  every  trace  of  eruption. 

VACCINIA 

(Vaccination;  cow-pox) 

Vaccinia  is  the  reaction  which  follows  inoculation  with  the 
vaccine  virus  or  virus  of  cowpox.  It  is  supposed  to  furnish  variably 
effective  immunity  against  smallpox.  Many  think  it  best  to  vac- 
cinate in  infancy  after  the  sixth  month,  at  the  seventh  or  eighth 
year,  at  puberty,  and  thereafter  at  intervals  depending  on  the 
prevalence  of  smallpox.  The  virus  is  prepared  under  sterile  con- 
ditions from  carefully  selected  and  tested  calves.  It  is  put  up  under 
aseptic  conditions  in  hermetically  sealed  capillary  tubes  or,  in  the 
old  style,  on  ivory  points. 

Technic.  The  area  selected  is  usually  the  left  arm  at  a  point  above  the 
insertion  of  the  deltoid  muscle.  The  leg  is  preferable  in  children  or  even  in 
adults,  as  it  is  easier  cared  for.  The  point  of  election  here  is  over  the  junction 
of  the  two  heads  of  the  gastrocnemius  muscle. 

The  skin  should  be  carefully  washed  with  soap  and  water  and  then  with 
alcohol. 

Sterilize  a  needle  or  lancet  and  scratch  an  area  about  a  quarter  of 
an  inch  in  diameter  at  the  selected  site,  being  careful  not  to  produce  bleeding 
but  merely  an  oozing  of  pinkish  lymph.  Deposit  the  drop  of  virus  upon  the 
abraded  area,  rub  in  with  the  side  of  the  needle,  and  let  dry.  Dress  with  a 
sterile  gauze  bandage  wrapped  several  times  around  the  arm  or  leg.  Prevent 
the  bandage  from  slipping  by  strips  of  adhesive  plaster. 

Diagnosis.  If  successful,  on  the  third  day  a  small  red  papule 
is  seen,  becoming  an  umbilicated  vesicle  on  the  sixth  day  and  a 
pustule  upon  the  eighth.  The  adjacent  tissues  are  red  and  infil- 
trated. Tenderness  and  itching  are  present.  The  areola  begins  to 
fade  by  the  tenth  day.  The  pustule  becomes  a  mahogany-brown 
crust  by  the  fourteenth  day  and  is  detached  by  the  twenty-third 
day.    The  resulting  scar  is  circular,  depressed,  foveated,  radiated, 


VACCINIA  547 

and  paler  than  the  surrounding-  skin.  This  process  is  accompanied 
by  varying  symptoms.  Slight  fever,  malaise,  restlessness,  glan- 
dular enlargement  and  other  constitutional  disturbances  are  often 
present.  The  younger  the  child  after  one  month  the  less  the 
disturbance.    The  axillary  or  the  inguinal  glands  are  often  swollen. 

Complications.  Not  all  cases  are  so  benign.  Infection  with 
pyogenic  organisms  results  in  abscesses,  erysipelas,  or  tetanus, 
and  various  eruptions.    Otitis  media  may  leave  deafness. 

During  the  first  three  days,  erythema,  urticaria,  vesicular  and 
bullous  eruptions,  and  invaccinated  erysipelas  may  be  found. 

After  the  third  day  the  commonest  complications  are  urticaria, 
lichen  urticarius,  erythema  multiforme,  or  accidental  erysipelas. 

About  the  end  of  the  first  week  there  may  be  generalized  vac- 
cinia, impetigo,  vaccinal  ulceration,  glandular  abscess,  septic  infec- 
tions, or  gangrene. 

After  involution  of  the  pocks  invaccinated  disease,  for  example 
Hodgkin's  disease,  syphilis  or  tuberculosis,  may  appear,  especially 
when  human  virus  has  been  used  or  the  technique  faulty. 

General  Vaccinia  (vaccinal  eruptive  fever;  vaccinola).  The 
eruption  appears  usually  from  the  fourth  to  tenth  day  after  vac- 
cination, the  lesions  appear  in  crops  successively,  pass  through  the 
four  stages  of  smallpox,  and  usually  subside  by  the  twenty-first 
day.  The  lesions  may  be  few  or  numerous  and  appear  upon  any 
portion  of  the  body.  Fever  may  be  absent  or  present  but  is  usually 
proportionate  to  the  extent  of  the  eruption  and  the  associated 
complications. 

Sore  Arm.  The  areola  about  the  fully  developed  vesicle  may 
spread  over  a  considerable  portion  or  the  whole  of  the  arm.  It 
may  give  rise  to  a  diffuse  cellulitis.  The  arm  is  red,  swollen,  hot, 
and  painful  and  there  is  apt  to  be  some  associated  systemic  dis- 
turbance. By  traumatism  to  the  vesicle,  an  ulcer  may  form.  The 
areola  may  become  hemorrhagic.     Localized  gangrene  may  occur. 

Treatment.  After  vaccinating,  the  patient  is  told  to  return  in 
seven  days.  The  dressings  are  then  removed  and  if  successful,  a 
pearl-like  vesicle  will  be  present.  If  it  is  broken  by  accident  or 
by  rubbing  of  the  gauze,  the  free  portions  of  the  dressing  are  cut 
away  and  the  adherent  part  left.  A  new  gauze  is  applied  in  either 
case.  In  five  or  six  days  more,  the  dressing  should  again  be 
changed  and  this  changing  continued  at  intervals  until  the  crust 
falls,  usually  from  the  third  to  the  fourth  week  after  vaccination. 

If  no  vesicle  forms  by  the  tenth  or  twelfth  day  the  vaccination 
is  unsuccessful. 

Prognosis.  Uneventful  recovery  is  expected.  Pitting  from  the 
generalized  vaccinia ;  various  constitutional  diseases ;  paralyses  and 


548  DISEASES  DUE  TO  UNKNOWN  AGENTS 

other  maiming  disabilities  sometimes  occur.    It  is  not  considered 
dangerous  to  life. 

Sequelae  are  usually  prevented  by  using  a  pure  vaccine  and  the 
use  of  aseptic  methods  and  antiseptic  care  afterward,  though  these 
do  occur  sometimes  un^er  the  best  of  care. 


VARICELLA 

(Chicken-pox) 

Varicella  is  an  acute,  contagious,  eruptive,  mildly  febrile  affec- 
tion, occurring  principally  among  children;  characterized  by  a 
moderate  fever,  the  appearance  on  the  first  day  of  a  maculo-vesicu- 
lar  rash  which  is  repeated  in  successive  crops,  and  the  desiccation 
and  falling  of  the  crusj;s  in  three  to  five  days. 

Chicken-pox  is  an  epidemic  disease  which  spreads  rapidly,  is 
caused  by  an  unknown  organism,  affects  children  under  ten  years 
the  most  frequently  although  adults  may  be  attacked,  is  highly 
contagious  but  not  inoculable,  and  confers  immunity.  It  bears  no 
relation  to  variola.  The  incubation  period  is  from  seven  to  seven- 
teen days,  usually  fourteen  days.  Among  predisposing  causes  we 
find  the  muscles  in  front  of  the  neck  and  behind  the  jaw  contracted, 
and  muscular  and  bony  lesions  of  the  clavicle  and  ribs. 

Diagnosis.  The  onset  is  sudden,  with  fretfulness,  moderate 
fever,  99°  to  101°  F.  persisting  during  the  course  of  the  disease, 
thirst,  anorexia,  constipation,  sometimes  vomiting,  and  furred 
tongue.  The  eruption  comes  out  within  fwenty-four  hours  and 
may  be  the  first  symptom  noticed  or  perhaps  the  child  had  been 
somewhat  feverish  and  restless. 

The  eruption  consists  at  first  of  hyperemic  macules,  then  papu- 
lar rose-colored  spots,  not  hard,  and  rapidly  converted  into  raised, 
flattened,  ovoid,  pin-head  to  pea-sized  vesicles  containing  a  fluid 
at  first  watery  then  pearly.  They  appear  on  the  chest,  neck,  face, 
scalp,  and  then  trunk  and  limbs  in  the  order  given,  being  most 
abundant  upon  the  back.  They  number  anywhere  from  eight  to 
several  hundred  and  are  usually  widely  scattered.  These  vesicles 
are  not  umbilicated  but  some  may  have  a  slightly  depressed  center, 
are  not  loculated,  are  discrete,  and  appear  in  successive  crops 
which  require  from  three  to  six  days  to  complete.  The  fresh 
roseolas  are  found  between  the  drying  ones  so  that  by  the  fifth 
day  one  may  find  all  stages  of  the  eruption  in  a  single  case.  There 
may  be  an  efflorescence  upon  the  mucous  membrane  of  the  oral 
cavity  and  of  the  pharynx  causing  slightly  difficult  deglutition. 
Sometimes  a  scarlatinoid  rash  precedes  the  true  eruption.  The 
itching  is  more  or  less  intense.  The  vesicles  always  dry  up,  form 
yellowish  spots  of  "dew  drop"  appearance,  and  a  brownish  crust 
which  drops  off  leaving  a  slightly  reddened,  sometimes  depressed 


VARICELLA  549 

spot.    Desiccation  usually  occurs  by  the  third  to  fifth  day  although 
it  may  be  present  on  the  first  or  second. 

Pitting  may  occur  if  the  vesicles  are  scratched.  Distinct  um- 
bilication  is  rare  and  pustulation  is  still  more  rare.  Muscular 
tension  of  the  cervical  muscles,  especially  those  in  the  front  and 
around  the  angle  of  the  inferior  maxillary,  clavicles  bound  down,' 
and  disturbed  relations  of  the  ribs  are  often  found.  Few  complica- 
tions occur.  Severe  itching  may  lead  to  scratching,  scars  or  even 
ulceration.  Gangrene  around  the  vesicles  (varicella  grangrenosa) 
occurs  in  debilitated  children,  those  tuberculous  and  congenital 
syphilitics.  It  is  apt  to  be  fatal.  Slight  enlargement  of  the  lymph 
glands  of  the  pharynx  may  persist.  Furunculosis  is  not  common 
except  among  those  in  very  unhygienic  surroundings.  Varicella 
bullosa,  nephritis  and  occasionally  otitis  media  and  bronchial  affec- 
tions may  occur. 

Treatment.    The  younger  children  should  be  put  to  bed  until' 
the  crusts  have  formed.  The  older  children  may  be  allowed  around 
the   room,     A   light   general   treatment  makes   the   little  patient 
more  comfortable  and  prevents  complications. 

"Be  very  careful  and  very  thorough  in  your  neck  adjustments.  Loosen 
the  atlas  and  axis  and  draw  forward  the  inferior  maxillary  from  its  pressure 
upon  the  vessels  and  nerves  back  of  its  angle.  Draw  the  hyoid  bone  forward 
and  secure  good  circulation  of  blood  throughout  the  entire  cervical  region." — 
A.  T.  Still. 

Give  a  bland  easily  digested  diet.  Overcome  the  constipation 
by  splanchnic  and  abdominal  manipulation  and  by  laxative  diet. 
During  active  eruption,  do  not  use  tub  baths.  Keep  the  nails 
short  and  very  clean.  Daily  tepid  sponging  with  either  plain  water 
or  boric  acid  solution  answers  both  as  an  antiseptic  wash  and 
bathing. 

After  the  daily  sponge  and  several  times  during  the  day  as 
needed  to  control  the  itching,  anoint  with  a  10%  boric  acid  oint- 
ment or  carbolized  vaseline.  When  the  scratching  cannot  be 
controlled  the  hands  may  be  tied  in  muslin  bags. 

The  ultra-violet  rays  of  light  seem  to  be  especially  irritating. 
The  parts  of  the  body  exposed  to  light  are  more  deeply  scarred, 
as  a  rule.  Hence,  the  use  of  a  dull  red  light  is  often  advised,  in 
order  to  diminish  the  scar  formation,  as  in  smallpox. 

The  prognosis  is  invariably  favorable  unless  serious  complica- 
tions arise  which  is  seldom.     Recurrences  very  rarely  occur. 

Prophylaxis.  The  child  should  be  considered  in. quarantine  for 
three  weeks  or  until  the  skin  is  wholly  clean. 

SCARLET  FEVER 

(Scarlatina) 
Scarlet'  fever,  is  an  acute,  specific,  contagious,  infectious,  ery- 
thematous  disease   of  childhood,   characterized   by   sudden   onset 


550  DISEASES  DUE  TO  UNKNOWN  AGENTS 

with  vomiting,  sore  throat,  punctiform  eruption  in  the  roof  of  the 
mouth,  high  fever,  very  frequent  pulse,  followed  in  twelve  to 
twenty-four  hours  by  a  bright  red  punctiform  rash,  by  a  desquama- 
tion often  in  large  flakes,  by  variable  degrees  of  severity,  and  by 
the  large  number  of  complications  and  sequelae,  especially  nephri- 
tis and  inflammation  of  the  serous  membranes. 

Etiology.  The  disease  is  due  to  an  unknown  agent.  Bacteria 
and  protozoa  have  been  described  by  various  bacteriologists.  The 
virus  is  very  resistant  to  heat,  light,  and  drying.  It  is  transmitted 
from  child  to  child  through  unclean  habits  of  eating  and  drinking. 
It  first  attacks  the  tonsils,  later  the  other  tissues,  and  leaves  the 
skin  and  the  mucous  membranes  with  broken  immunity  to  various 
other  infections.  The  disease  is  epidemic,  rarely  sporadic.  Con- 
tagion is  carried  by  direct  contact,  fomites  and  by  milk.  The  secre- 
tions of  the  respiratory  tract,  the  desquamated  epithelium,  and 
articles  used  by  the  patient  are  infectious.  Predisposing  factors 
are:  lesions  both  bony  and  muscular  interfering  with  vitality,  the 
autumn  and  winter,  age  between  six  months  and  ten  years,  puer- 
peral women  and  open  wounds. 

Pathology.  No  specific  lesions  are  found.  No  trace  of  the  rash 
shows  after  death  except  in  the  hemorrhagic  form.  The  anatomical  changes 
in  cases  coming  to  autopsy  are  those  of  simple  inflammation,  foHicular  ton- 
sillitis, or  diphtheroid  angina.  Streptococci  are  abundantly  found  in  the  glands 
and  foci  of  suppuration.  The  lymph  glands  and  lymphoid  tissue  may  show 
hyperplasia. 

Diagnosis.  Invasion  is  sudden,  with  usually  vomiting,  some- 
times convulsions  in  the  younger  children;  sore  throat;  intense 
fever,  103°  F.  or  higher,  on  the  first  day;  pulse  120  to  150  per 
minute,  unduly  rapid  for  the  temperature;  respirations  increased; 
the  glands  at  the  angle  of  the  jaws  swollen ;  insomnia,  and  noc- 
turnal delirium  which  disappears  as  the  rash  comes  out.  The 
skin  and  muscles  of  the  back  are  hypersensitive  to  touch  and  to 
extremes  of  heat  and  cold. 

At  the  end  of  the  first  day  or  a  little  later  the  rash  appears.  It 
is  composed  of  scattered  scarlet  red  points  on  a  deep  subcuticular 
flush,  appearing  first  upon  the  neck  and  chest,  spreading  rapidly 
so  that  by  the  evening  of  the  second  day  it  has  invaded  the  entire 
skin  except  for  a  circle  around  the  eyes,  nose  and  chin  and  is 
most  intense  upon  the  trunk  and  the  flexor  surfaces.  The  throat 
shows  reddening  of  the  pharynx  and  uvula,  the  tonsils  enlarged 
and  with  often  creamy-white  patches  covering  the  mouths  of  the 
follicles.  The  temperature  persists  and  may  even  reach  104°  to 
105°  F.  Itching  and  burning  are  annoying  at  times.  There  may 
be  considerable  swelling  of  the  skin. 

The  eruption  reaches  its  height  between  the  second  and  third 
days  when  it  has  a  vivid  scarlet  hue  unlike  any  othei*  eruption, 
becoming  darker  each  day  until  it  may  be  bluish-red,  when  it 


SCARLET  FEVER  551 

gradually  fades  and  desquamation  begins.  During  this  time 
papules  are  often  seen.  Also  sudaminal  vesicles  may  develop  so 
that  the  skin  is  covered  with  small  yellowish  vesicles  upon  the 
red  background  (scarlatina  miliaris).  A  pimctiform  eruption  in 
the  arm-pits,  groins,  or  roof  of  the  mouth  is  considered  positive 
proof  of  scarlet  fever.    There  may  be  fine  punctiform  hemorrhages. 

By  the  seventh  or  eighth  day,  the  rash  has  disappeared  together 
with  the  fever.  The  skin  looks  somewhat  stained,  is  a  little  rough 
like  "goose  skin,"  and  gradually  the  upper  layers  begin  to  separate, 
first  about  the  neck  and  chest,  and  coming  off  in  large  lamellae 
or  flakes.  This  may  repeat  in  individual  areas.  Casts  of  the  fin- 
gers or  toes  may  be  shed.  This  process  lasts  from  four  to  eight 
weeks. 

The  tongue  at  first  is  red  at  the  tip  and  margins  with  a  grayish- 
yellow  or  whitish  fur  in  the  center  through  which  are  often  seen 
the  swollen  red  papillae,  the  "strawberry  tongue."  The  "fur" 
desquamates  upon  the  third  or  fourth  day  leaving  a  surface  in- 
tensely red  with  markedly  raised,  swollen  papillae,  the  "raspberry 
tongue  or  cat  tongue,"  lasting  nearly  a  full  week.  The  breath  has 
a  heavy  sweet  odor.    There  are  several  types  of  this  disease. 

Mild  and  abortive  form  (scarlatina  sine  eruptione).  In  this  the 
rash  may  be  scarcely  perceptible,  while  the  fever,  sore  throat,  and 
strawberry  tongue  are  present.  Desquamation  may  occur  and 
serious  nephritis  follow. 

The  malignant  forms  include  fulminant  toxic  or  atactic  variety, 
in  which  there  is  onset  with  great  severity,  high  fever  107°  to 
108°  F.,  and  extreme  restlessness,  headache,  and  delirium.  Con- 
vulsions may  occur,  sometimes  vomiting  and  diarrhea;  initial  de- 
lirium gives  place  to  coma ;  dyspnea  may  be  urgent ;  pulse  very 
rapid  and  feeble,  and  death  occur  in  twenty-four  to  thirty-six 
hours  from  the  intense  toxemia. 

In  the  hemorrhagic  variety  there  are  hemorrhages  into  the 
skin,  beginning  with  scattered  petechiae,  becoming  more  extensive 
and  ultimately  involving  the  whole  skin. 

Severe  epistaxis  and  hematuria  are  common.  Death  may  take 
place  on  the  second  or  third  day.  This  is  more  common  in  en- 
feebled children  although  it  may  attack  adults  in  apparently  full 
health. 

Anginose  variety  (scarlatina  anginosa).  The  throat  symptoms 
appear  early  and  progress  rapidly.  Temperature  to  105°  to  107°  F., 
cyanosis,  diarrhea,  rapid  weak  irregular  pulse,  and  stupor  occur. 
The  fauces  and  tonsils  are  covered  with  a  thick  membranous 
exudate  which  may  extend  to  the  posterior  wall  of  the  pharynx, 
forward  into  the  mouth,  upward  into  the  nasal  chambers,  and  may 
occasionally  reach  the  trachea  and  bronchi.  The  Eustachian  tube 
and  the  middle  ear  are  usually  involved.    The  glands  of  the  neck 


552  DISEASES  DUE  TO  UNKNOWN  AGENTS 

rapidly  enlarge  and  become  the  seat  of  brawny  induration,  and  the 
inflammation  extends  beyond  their  limits.  Necrosis  occurs  in 
the  tissues  of  the  throat,  fetor  is  extreme,  the  constitutional  symp- 
toms are  great  and  the  child  dies  from  toxemia.  If  he  does  not 
succumb,  extensive  abscess  formation  in  the  tissues  of  the  neck 
takes  place  with  sloughing  and  danger  of  hemorrhage  from  the 
opening  of  a  large  artery. 

The  spinal  examination  usually  shows  muscular  contractions 
throughout  the  entire  length  but  these  are  more  prominent  at 
the  upper  dorsal,  in  and  around  the  eleventh  and  twelfth  dorsal 
and  in  the  upper  cervical  areas.  Bony  subluxations  may  be  found 
anywhere. 

The  physical  examination  has  no  special  features.  The  spleen 
may  be  palpable  but  the  liver  is  not  often  enlarged. 

The  blood  pressure  rises  at  first,  thereafter  it  follows  the  pulse 
and  temperature.  After  the  seventh  or  eighth  day,  it  may  be 
below  normal.  Cases  with  albuminuria  show  hypertension  and 
slowing  of  the  heart  action.  With  the  subsidence  of  the  kidney 
irritation  the  pulse  rate  is  increased  and  the  blood  pressure  returns 
to  normal. 

The  urine  shows  the  ordinary  febrile  character,  being  scanty 
and  high  colored.  Slight  albuminuria  is  rather  common  after  the 
stage  of  eruption,  even  a  few  tube  casts  may  be  present  with- 
out any  serious  irritation  of  the  kidney.  The  examination  should 
be  made  daily. 

Blood.  The  red  cells  are  moderately  reduced  to  3,000,000  or 
4,000,000  per  cmm.  during  convalescence.  There  may  be  some 
poikilocytosis  and  normoblasts  are  occasionally  seen.  Leucocyt- 
osis  is  early,  15,000  to  30,000  per  cmm.,  falling  with  the  decline 
of  the  fever  usually  by  the  fourteenth  day,  but  may  persist  for 
weeks  after  the  temperature  is  normal.  The  count  runs  roughly 
parallel  to  the  temperature.  Over  40,000  leucocytes  per  cmm.  are 
of  bad  prognostic  omen.  Polymorphonuclear  cells  are  increased 
to  80%  to  90% ;  early  returning  to  normal  in  favorable  cases. 

Eosinophilia  is  present  in  all  but  malignant  cases.  It  reaches 
its  maximum  two  or  three  days  after  the  rash  appears  and  returns 
to  normal  after  the  leucocytosis  has  disappeared.  The  early  pres- 
ence of  eosinophilia  excludes  septic  conditions.  When  these  cells 
are  absent  in  scarlet  fever,  myelocytes  are  to  be  found. 

The  symptom  complex  which- is  pathognomonic  of  scarlet  fever 
is  the  changed  condition  of  the  tongue,  the  angina,  the  exanthem, 
and  the  fever.  The  diagnosis  is  not  usually  difficult,  but  may  be 
confounded  with  the  following  conditions:  acute  exfoliating  der- 
matitis, measles,  rotheln,  septicemia,  diphtheria  or  antitoxin  ery- 
thema, acute  follicular  (lacunar)  tonsillitis,  and  the  drug  eruptions. 

Treatment.  Complete  isolation  with  a  competent  nurse,  a  light, 
quiet,  thoroughly  ventilated  room  of  a  constant  temperature  (if 


SCARLET  FEVER  553 

possible  two  rooms,  one  for  day  and  the  other  for  night;  situated 
upon,  an  upper  floor),  and  suitable  means  for  thorough  disinfect- 
tion  of  all  articles  used  in  the  sick-room  are  essential  elements  of 
treatment.  The  child  should  wear  its  customary  night  apparel. 
The  bed  clothing  should  not  be  too  heavy. 

Thorough  osteopathic  treatment  should  be  given  along  the 
spinal  region  from  the  atlas  to  the  sacrum  inclusive,  to  keep  the 
muscles  well  relaxed,  giving  special  attention  to  the  relationship 
between  the  atlas  and  the  occiput,  the. cervical  vertebrae  and  the 
deep  cervical  muscles,  especially  those  muscles  at  the  angle  of 
the  inferior  maxillary  and  those  at  the  base  of  the  occiput,  also 
much  attention  to  the  renal  splanchnics. 

Adjust  the  clavicles  by  bringing  fairly  well  forward  to  relieve 
any  irritation  that  might  be  started  in  that  area.  Direct  treatment 
to  the  abdomen  should  usually  be  given  at  each  visit  besides  the 
work  in  the  splanchnic  area  to  keep  the  bowels,  kidneys  and  liver 
active.    Careful,  deep  work  over  the  ureters  is  beneficial. 

Diet.  Water  must  be  freely  given.  Pellets  of  ice  to  hold  in 
the  mouth  are  a  comfort  during  the  fever.  Fruit  juices,  especially 
orange,  are  best  during  the  fever.  For  infants,  cut  down  their 
feedings  to  half,  making  the  milk  very  thin  with  water  or  gruel. 
After  defervescence,  carefully  increase  to  a  light  diet  using  spar- 
ingly of  nitrogenous  foods  except  milk.  After  four  weeks  in  a 
usual  case,  gradually  return  to  the  ordinary  food.  This  is  a  good 
time  to  make  corrections  in  the  ordinary  diet  if  any  are  needed. 

The  bowels  must  be  kept  regulated.  An  enema  is  usually  indi- 
cated after  the  onset  of  the  disease.  During  the  time  when  food 
is  permitted,  it  should  be  of  a  laxative  quality.  A  tepid  sponge 
should  be  given  at  least  once  daily.  The  nose  may  be  cleansed  by 
instillation  by  means  of  a  medicine  dropper,  using  normal  salt 
solution. 

If  the  throat  symptoms  are  mild,  a  gargle  of  normal  salt  solu- 
tion is  enough  for  cleanliness  of  the  membrane.  If  the  throat 
symptoms  are  too  severe  to  permit  the  use  of  the  gargle,  or  if  the 
patient  is  too  small  to  be  taught  to  gargle  or  to  wash  the  throat, 
irrigation  may  be  employed. 

The  teeth  should  be  thoroughly  and  carefully  brushed  twice 
each  day.  The  skin  must  be  kept  comfortable.  "Using  carbolized 
water  (1:40)  to  sponge  the  surface,  followed  by  the  application 
of  cocoa  butter,  will  tend  to  reduce  the  fever  by  soothing  the 
cutaneous  burning  and  irritation ;  and  later  when  desquamation 
occurs  limits  the  source  of  infection  by  preventing  the  diffusion 
of  what  would  be  dry  scales  in  the  air." — McConnell  and  Teall. 

During  desquamation  after  bathing  the  child  should  be  thor- 
oughly rubbed  and  then  the  oily  application  used.  Besides  the 
cocoa  butter,  cold  cream  (nonmedicated),  liquid  albolene,  or  the 


554  DISEASES  DUE  TO  UNKNOWN  AGENTS 

like  may  be  used.  Olive  oil  and  vaseline  are  usually  irritating  at 
this  stage. 

A  temperature  above  102**  can  usually  be  lowered  by  steady, 
deep  pressure  applied  in  the  suboccipital  region  for  a  few  minutes, 
then  followed  by  relaxation  of  the  back  muscles  from  the  first  to 
seventh  dorsal,  by  raising  and  spreading  the  ribs  in  that  area 
especially  the  fifth  and  sixth,  and  attention  to  the  fifth  lumbar 
region.  When  the  fever  is  rapidly  rising  but  the  child  is  not 
delirious  a  tub  bath  may  be  given.  The  cold  pack  may  be  used 
when  the  patient  has  pronounced  delirium  and  nervous  symptoms. 
The  ice-cap  is  useful  and  may  be  used  constantly  in  high  fever. 

Severe  sore  throat  is  usually  relieved  by  the  treatment  given 
and  the  throat  toilet.  Treatment  around  the  hyoid  bone  to  relax 
the  muscles  and  to  correct  maladjustments  is  needed.  With  the 
first  sign  of  a  swollen  gland,  begin  treatment  by  crowding  the 
tissues  toward  the  gland  but  never  working  upon  the  gland  itself. 
This  secures  drainage  and  relief  unless  malignant  pyogenic  organ- 
isms are  present. 

If  pain  is  feJt  in  the  ear,  attention  must  be  given  immediately. 
Upper  cervical  treatment  consisting  of  correction  of  any  deviation 
of  the  atlas  or  other  vertebrae,  relaxing  the  deep  muscles  at  the 
angle  of  the  jaw  and  relieving  any  impingements  at  the  upper 
thoracic  region  must  be  thoroughly  employed.  If  the  pain  is  not 
bad,  the  nurse  may  be  directed  to  use  a  drop  of  warm  glycerine  or 
oil  in  the  external  auditory  canal.  If  there  is  reason  to  suspect 
the  existence  of  surgical  complications,  an  ear  specialist  should 
be  consulted.  The  condition  of  the  drum  membrane  should  be 
examined  every  day.  If  the  drum  is  bulging,  deeply  congested  and 
the  landmarks  indistinct,  paracentesis  should  be  performed. 

The  heart  should  be  examined  daily.  Vigorous  treatment 
through  the  thoracic  region  is  indicated,  if  cardiac  symptoms 
appear,  and  the  patient  kept  quiet  and  in  bed. 

If  arthritis  occurs  the  affected  joint  must-be  wrapped  in  flannel 
or  in  cotton  wool,  and  the  treatment  given  under  Acute  Rheuma- 
tism administered.  If  albuminuria  increases,  the  condition  of  the 
kidneys  must  receive  prompt  attention.  Look  for  lesions  around 
the  tenth  to  twelfth  dorsal  vertebrae  or  the  ribs  attached  thereto, 
correct  deviations,  and  keep  tissues  constantly  relaxed. 

After  the  temperature  has  been  normal  for  ten  days,  the  patient 
may  be  allowed  to  get  up.  For  at  least  three  weeks  great  care 
should  be  exercised  to  prevent  exposure  to  cold  or  to  other  infec- 
tions. Renal  complications  are  most  apt  to  occur  during  con- 
valescence. 

The  patient  must  be  seen  from  once  to  three  times  a  day  accord- 
ing to  the  severity  of  the  case. 


SCARLET  FEVER  555 

Prognosis.  Epidemics  differ  in  severity  and  in  mortality.  The 
mortality  is  greater  in  hospitals,  among  the  poorer  classes,  and  in 
children  under  one  year  of  age.  Very  high  fever,  early  mental 
disturbances,  hemorrhages,  intense  diphtheroid  angina,  laryngeal 
obstruction  and  nephritis  cloud  the  prognosis.    Most  cases  recover. 

Recurrences  seldom  occur.  Sequelae  are  frequent.  These  in- 
clude nephritis,  deafness  due  to  otitis,  cardiac  lesions,  rhinorrhea, 
otorrhea,  and  throat  troubles.  These  should  not  occur  in  cases 
properly  handled. 

Prophylaxis.  The  child  is  infective  for  from  eight  to  thirteen 
weeks,  usually  until  after  desquamation  is  complete.  If  left  with 
any  rhinorrhea,  otorrhea,  or  throat  trouble  he  is  especially  infec- 
tious, though  he  may  seem  in  perfect  health.  The  period  of  quar- 
antine for  suspected  cases  is  ten  days  after  exposure ;  if  it  develops 
the  period  of  isolation  is  six  weeks. 

Complications.  Patients  who  receive  correct  osteopathic  treat- 
ment from  the  onset  of  the  disease  rarely  suffer  from  complications 
or  sequelae.    The  following  may  occur: 

Nephritis  is  most  common  in  the  second  and  third  week  of 
illness,  rarely  the  fourth,  but  may  develop  as  late  as  the  sixth. 
The  nephritis  may  be  hemorrhagic,  in  which  the  urine  is  sup- 
pressed or  there  may  be  a  very  small  amount  of  bloody  fluid  laden 
with  albumin  and  tube  casts;  constant  vomiting  and  convulsions 
follow  and  the  child  dies  with  symptoms  of  acute  uremia. 

In  less  severe  cases  there  may  be  a  puffy  appearance  of  eye- 
lids, slight  edema  of  the  feet,  urine  diminished  in  quantity,  smoky, 
containing  albumin  and  tube  casts.  The  kidney  symptoms  domi- 
nate, dropsy  persists  and  there  may  be  effusion  into  the  serous 
sacs.  The  condition  may  become  chronic,  the  patient  may  suc- 
cumb to  uremia;  in  the  majority  of  cases  recovery  takes  place. 

In  the  milder  cases  the  urine  contains  albumin  and  a  few  tube 
casts,  very  rarely  blood,  and  edema  is  slight  or  transient.  Con- 
valescence is  scarcely  interrupted,  or  serious  symptoms  supervene, 
or  edema  disappears  and  the  child  improves  but  remains  pale  and 
with  a  slight  trace  of  albumin  in  urine  for  months^  then  recovery 
or  chronic  nephritis. 

Severe  scarlatinal  pyemia  may  be  attended  with  suppuration 
of  one  or  more  joints  and  is  usually  fatal. 

Polyarthritis  or  true  scarlatinal  rheumatism  occurs  during  the 
second  or  third  week.  Many  joints  are  attacked  especially  the 
small  joints  of  the  hands.  There  may  be  inflammation  of  the  ten- 
don sheaths,  heart  may  be  involved,  and  the  outlook  is  usually 
good  for  recovery. 

Malignant  endocarditis  occurs  in  the  severe  septic  cases,  some- 
times with  a  purulent  pericarditis,  and  is  fatal. 


556  DISEASES  DUE  TO  UNKNOWN  AGENTS 

Severe  toxic  myocarditis  is  sometimes  present,  leading  to  acute 
dilatation  and  sudden  death.  Simple  endocarditis  is  not  uncom- 
mon and  may  give  no  symptoms.  Signs  of  slight  enlargement 
may  persist  after  convalescence  and  valvular  lesion  may  result. 
Acute  bronchitis  and  pneumonia  are  not  common.  Empyema  is  an 
insidious  and  serious  complication. 

Otitis  media  is  a  common  and  serious  complication  owing  to 
the  extension  of  the  inflammation  through  the  Eustachian  tubes. 
It  is  the  most  frequent  cause  of  deafness  in  children.  Extension 
from  the  middle  ear  to  the  labyrinth  rapidly  produces  deafness, 
to  the  mastoid  cells,  suppurative  mastoiditis.  From  the  necrosis 
following  middle  ear  disease  there  may  be  paralysis  of  the  facial 
nerve,  thrombosis  of  the  lateral  sinus,  meningitis,  and  abscess  of 
the  brain. 

The  swelling  of  the  neck  may  extend  beyond  the  lymph  nodes. 
This  usually  subsides  within  a  few  weeks,  the  most  extreme  en- 
largement gradually  disappearing. 

Acute  phlegmonous  inflammation  (angina  ludovici)  may  occur 
with  widespread  destruction  of  tissue.  Vessels  may  be  eroded  and 
fatal  hemorrhage  ensue. 

The  nervous  complications  include  chorea,  sudden  convulsions 
followed  by  hemiplegia,  and  mental  symptoms  as  mania  and  mel- 
ancholia. Progressive  paralysis  of  the  limbs  with  wasting,  may 
simulate  infantile  paralysis. 

Rare  complications  are :  edema  of  the  eyelids  without  nephritis, 
symmetrical  gangrene,  enteritis,  noma,  and  perforation  of  the  soft 
palate.  The  fever  may  persist  after  the  eruption  disappears  and 
the  child  remain  in  a  septic  state  (scarlatinal  typhoid). 

Relapses  are  rare.  Scarlatina  may  coexist  with  almost  any 
of  the  other  acute  infections.  It  lowers  the  resistance  of  the  body 
to  disease  and  is  often  followed  by  other  acute  infections  or  by 
tuberculosis. 

MEASLES 

(Morbilli',  rubeola) 

Measles  is  an  acute,  infectious,  erj^thematous,  contagious  dis- 
ease, characterized  by  an  incubation  period  of  about  ten  days; 
by  catarrhal  symptoms  of  the  naso-bronchial  mucous  membranes; 
by  a  typical  temperature  curve ;  by  the  presence  of  Koplik's  buccal 
spots;  and  by  a  papular  eruption  appearing  upon  the  fourth  day 
and  terminating  in  a  branny  desquamation. 

Etiology.  The  infectious  agent  has  not  been  found.  The  dis- 
ease occurs  chiefly  among  children;  is  epidemic  and  rarely  spo- 
radic; is  transmitted  by  the  respiratory  secretions,  fomites  and 


MEASLES  557 

through  a  third  person;  and  is  extremely  infectious  during  the 
incubation  and  the  eruption. 

The  incubation  period  is  from  seven  to  eighteen  days.  Cervical 
and  upper  dorsal  lesions  involving  the  vasomotors  to  the  mucous 
membranes  of  the  respiratory  tract  and  to  the  lymphatics  drain- 
ing it  are  predisposing  factors. 

Diagnosis.  Known  exposure  to  infection  or  the  presence  of 
an  epidemic  are  the  only  history  factors. 

The  stage  of  invasion  begins  with  chilliness  or  a  decided  chill, 
fever  rapidly  rising  to  101°  to  104°  F.  on  the  first  day;  pulse  rate 
increasing  with  the  fever  to  120  to  140  times  per  minute ;  headache, 
muscular  soreness,  intense  nasal,  pharyngeal  and  laryngeal  catarrh ; 
photophobia  with  red  watery  eyes ;  sneezing  and  a  croupy  cough ; 
hoarse  voice,  sometimes  nausea  and  vomiting.  Small,  irregular 
spots  of  a  bright  red  color,  each  having  a  bluish-white  center, 
upon  the  buccal  mucous  membranes  within  the  lips  and  upon  the 
gums  are  called  Koplik's  spots.  They  appear  upon  the  first  day 
and  fade  upon  the  appearance  of  the  dermal  eruption,  and  are 
considered  pathognomonic  of  measles.  On  the  second  or  third 
day,  the  fever  remits  to  normal  or  subfebrile.  On  the  fourth  day, 
the  temperature  rises  again,  increasing  as  the  rash  develops,  to 
104°  or  105°  F.  and  reaching  its  maximum  on  the  sixth  day  when 
it  falls  by  crisis ;  on  the  seventh  or  eighth  day  the  temperature  is 
normal.  The  eruption  consists  of  small,  dark  red  macules  with 
minute  papules  in  the  center  of  each  somewhat  raised,  arranged 
in  crescentic  groups,  velvety  to  the  touch,  which  may  become 
confluent,  and  disappear  on  pressure. 

They  appear  at  the  hair-line  of  the  forehead  and  spread  over 
the  chest,  trunk,  and  entire  body.  The  eruption  is  attended  by 
itching  and  burning,  and  develops  completely  in  twelve  to  thirty- 
six  hours,  while  the  catarrhal  symptoms  still  persist.  About  the 
ninth  day  the  rash  begins  to  fade,  first  from  the  face  and  neck, 
leaving  a  yellowish  discoloration,  and  disappears  entirely  in  a 
bran-like  desquamation,  which  usually  lasts  several  days  to  a 
week. 

There  are  several  varieties. 

Measles  without  eruption  (morbilH  sine  exanthemati,  morbilli 
sine  morbillis)  is  a  form  in  which  the  S3-mptoms  are  typical  up  to 
the  eruptive  stage  but  this  fails  to  appear  and  convalescence  is 
established. 

Black,  hemorrhagic  or  malignant  measles  is  severe  and  fatal. 
The  onset  is  usually  violent  with  high  fever  and  nervous  symp- 
toms. The  eruption  is  bluish  or  purplish  and  fails  to  disappear 
upon  pressure. 

Other  hemorrhages  in  the  form  of  petechise,  ecchymoses,  or 
bleeding  from  mucous  surfaces  may  occur.    The  patient  is  rapidly 


558  DISEASES  DUE  TO  UNKNOWN  AGENTS 

exhausted,  the  pulse  frequent  and  thready,  the  skin  pale  and  cold 
and  death  ensues. 

Adynamic  measles  is  a  serious  type  in  which  the  symptoms 
are  grave  from  the  outset  but  without  hemorrhages  and  the 
typhoid  status  is  early  present. 

The  most  common  complication  is  bronchopneumonia.  Others 
are  capillary  bronchitis,  -otitis  media,  severe  stomatitis  and  gastro- 
enteritis. 

The  spinal  examination  shows  cervical  and  upper  dorsal  con- 
tractions with  lesions  of  the  upper  four  ribs  and  clavicle.  "During 
all  examinations  of  such  patients,  I  have  found  muscular  contrac- 
tions at  the  union  of  neck  with  the  head." — A.  T.  Still. 

The  physical  examination  shows  the  buccal  spots,  a  tongue 
coated  with  somewhat  turgescent  papilli,  and  the  eruption. 

The  blood  pressure  is  usually  low.  The  urine  shows  no  special 
changes  except  those  of  fever  in  general. 

The  blood  shows  leucopenia  before  and  during  the  eruption, 
the  eosinophiles  are  normal  or  usually  diminished  during  the 
febrile  stage  or  they  may  disappear  altogether.  The  red  cells  are 
practically  normal.  The  decided  diminution  of  eosinophiles  is  of 
considerable  diagnostic  value.  If  there  is  increased  inflammation 
of  the  mucous  surfaces  the  fibrin  content  is  increased.  During 
convalescence  the  lymphocytes  and  large  mononuclears  are  in- 
creased. 

Treatment.  As  soon  as  a  susceptible  individual  is  exposed  to 
infection,  he  should  be  isolated,  watched  and  whatever  is  found 
improper  in  diet,  hygiene,  or  structural  relationships  corrected. 

On  invasion,  the  patient  should  be  put  to  bed  in  an  isolated, 
well-ventilated  room  of  constant  temperature  from  which  all  hang- 
ings, rugs,  and  curtains  have  been  removed.  The  windows  should 
be  shaded  especially  to  prevent  thin  rays  of  light,  and  when 
artificial  lights  are  necessary,  these  must  be  shaded. 

The  treatment  includes  the  relaxation  of  the  contracted  mus- 
cles, adjustment  of  bony  lesions  as  found,  raising  the  ribs  and 
increasing  the  mobility  of  the  thorax  and  especially  of  the  dorsal 
region.  Manipulations  which  are  very  painful  or  difficult  should 
be  avoided  during  the  progress  of  the  disease.  Dr.  Still  says, 
"The  arms  must  be  raised  and  the  axillary  regions  freed  at  once 
and  kept  so." 

"Isolation  is  of  great  importance,  and  should  be  carried  out  in  every  case. 
I  would  like  fo  emphasize  the  importance  of  isolating  practically  all  cases 
of  coryza  in  localities  where  are  cases  of  measles.  If  not  measles,  no  harm 
is  done;  if  the  case  is  measles,  then  you  have  likely  prevented  the  communica- 
tion of  the  disease  to  several  possible  victims.  .  .  .  The  room  should  be 
well  ventilated  with  a  temperature  of  about  70  degrees,  avoiding  direct  draft 
on  the  patient :  The  diet  should  be  that  of  any  acute  febrile  condition,  and  I 
strongly  advise  during  the  height  of  the  fever  that  nothing  but  water  be  admin- 


MEASLES  559 

istered,  .  .  .  Two  or  three  treatments  a  day  during  acute  stage  have  given 
me  the  best  results  in  these  cases.  The  treatment  is  confined  almost  exclusively 
to  a  light  stimulation  of  the  upper  dorsal  region  with  the  patient  lying  on 
the  back,  and  also  a  gentle  but  thorough  relaxation  of  the  cervical  region  with 
considerable  traction  of  same.  .  .  .  During  the  fever,  warm  or  even  slightly 
cool  sponge  baths  are  beneficial,  but  no  other  bathing  advised." — ^J.  Ferguson. 

In  the  beginning  it  is  usually  necessary  to  give  an  enema.  The 
bowels  must  be  kept  open  during  the  course  of  the  disease  by  diet 
and  manipulation.  The  diet  during  the  attack  should  be  light, 
suited  to  the  age  of  the  patient.  Plenty  of  water  is  urgently 
required.  The  temperature  is  usually  controlled  by  the  treatment, 
but  if  it  stays  over  104°  F.  for  an  hour  or  longer  and  the  physician 
cannot  reach  the  patient,  direct  the  nurse  to  give  a  tepid  sponge 
bath  of  ten  to  twenty  minutes'  duration  and  repeat  at  intervals  of 
two  to  three  hours. 

For  the  irritation  of  the  skin,  a  tepid  bath  with  water  at  100°  F. 
given  twice  daily  should  be  used  and  the  patient  dried  carefully 
and  an  application  of  cold  cream,  liquid  albolene,  or  olive  oil  made 
over  the  entire  body.  The  cough  is  best  relieved  by  thorough  treat- 
ment of  the  anterior  and  posterior  thoracic  regions  and  any  sub- 
luxations of  the  upper  ribs  or  clavicle  corrected.  Keeping  the 
air  of  the  room  moist  with  vapor  is  agreeable  to  the  congested 
mucous  surfaces.  During  the  waking  hours,  the  eyes  should  be 
generously  bathed  every  hour  or  two  with  a  three  per  cent  solution 
of  boric  acid  using  cotton  which  is  destroyed  after  use.  Dark 
glasses  in  a  well-ventilated  room  are  better  than  unaired  dark- 
ness. 

The  mouth  and  nose  must  be  carefully  cleansed  at  regular 
intervals  and  the  cloths  burned.  An  otoscopic  examination  should 
be  made  every  second  day  until  the  case  is  discharged.  The  con- 
dition of  the  lungs  must  be  examined  daily. 

If  the  rash  is  slow  in  appearing  and  the  child  is  very  uncom- 
fortable from  the  high  fever  (104°  to  105°)  a  hot  bath  (105°  to 
110°  F.)  for  three  to  five  minutes  will  often  bring  out  the  rash  and 
relieve  the  urgent  symptoms. 

During  convalescence,  the  patient  must  be  guarded  against 
cold.  Recovery  is  hastened  by  such  treatment  as  is  indicated  by 
the  conditions  found  on  examination,  and  should  be  given  two  or 
three  times  each  week. 

Prognosis.  Nearly  all  uncomplicated  cases  recover.  In  the 
hemorrhagic  and  adynamic  forms,  the  majority  succumb.  One 
attack  usually  confers  immunity.  Second  attacks  probably  never 
occur. 

Sequelae  are  frequent  but  are  prevented  by  careful  nursing 
during  convalescence. 

"In  and  of  itself  measles  is  usually  not  particularly  serious,  but  the  after- 
effects are  so  far-reaching  and  so  serious  that  students  of  the  history  of  med- 


560  DISEASES  DUB  TO  UNKNOWN  AGENTS 

icine  rank  measles  third  among  infectious  diseases  for  causing  death.  During 
recovery  from  measles  the  patient  stands  in  special  danger  from  pneumonia, 
and  pneumonia  following  measles  is  more  dangerous  than  uncomplicated 
pneumonia.  There  is  a  considerable  length  of  time  during  which  he  is  par- 
ticularly susceptible  to  tubercular  infection.  This  is  so  often  insidious,  and 
its  evidences  are  so  obscure,  that  by  the  time  the  disease  has  fully  developed 
one  may  have  forgotten  the  mild  attack  of  measles  which  really  paved  the  way 
for  the  serious  malady." — C.  A.  Whiting. 

Prophylaxis.  During  an  epidemic,  all  children  should  be 
guarded  from  exposure.  If  possible,  each  child  should  be  exam- 
ined in  order  to  see  that  no  lesions  or  other  predisposing  causes 
of  lowered  resistance  are  present.  At  any  rate,  when  measles 
makes  its  appearance  in  any  family,  or  when  children  are  sup- 
posed to  have  been  exposed,  the  treatment  should  be  begun  at 
once.  There  is  no  doubt,  in  the  minds  of  those  who  have  cared 
for  children  in,  this  way,  that  the  percentage  of  infection  following 
exposure  is  lessened  by  beginning  treatment  before  the  onset  of 
the  disease;  and  also  that  when  infection  is  found  to  be  unavoid- 
able, the  disease  runs  a  much  milder  course  than  is  the  case  when 
the  osteopathic  physician  is  sent  for  only  after  the  attack  has  made 
a  pronounced  beginning.  Children  known  to  be  exposed  should 
be  at  once  isolated.  After  all  catarrhal  symptoms  have  disap- 
peared the  patient  may  be  disinfected  and  removed  to  another 
room  and  the  sick  room  thoroughly  disinfected.  The  quarantine 
period  is  sixteen  days  unless  modified  by  the  health  authorities. 

.  To  sum  up  the  prophylactic  measures,  isolation,  disinfection 
of  fomites,  skin  and  secretions  from  the  nose  and  mouth,  and  the 
final  disinfection  of  the  sick  room  are  necessary. 


:rubella 

(German  measles;  Rotheln;  epidemic  roseola;  French  measles;  false  or  hybrid 
measles,  or  hybrid  scarlatina) 

Rubella  is  an  acute,  specific,  infectious,  contagious,  eruptive 
fever ;  attended  by  mild  fever,  suflfused  eyes ;  mild  cough ;  sore 
throat,  but  no  catarrh ;  a  macular,  rose-red  eruption  on  the  throat, 
accompanied  by  swelling  of  the  cervical  lymphatic  glands  and  by  a 
rose-colored  eruption  of  irregular  size  and  shape  appearing  on  the 
first  day  of  the  disease.  There  is  hypersensitiveness  in  the  suboc- 
cipital regions,  and  also  in  the  midthoracic.  Muscular  contractions 
are  not  marked  and  chiefly  affect  the  hyoid,  mandibular  and 
cervical  groups. 

The  infectious  agent  is  unknown,  is  carried  by  fomites,  attacks 
children  especially,  and  occurs  in  epidemics  or  sporadic  cases.  Chil- 
dren recovering  from  other  infectious  diseases  are  particularly 
susceptible.  The  incubation  period  is  from  five  to  twenty-one 
days  and  is  without  symptoms.    One  attack  confers  immunity. 


RUBEUA  561 

Diagnosis.  The  onset  is  sudden  with  chilliness,  mild  fever 
100°  to  101°  F. ;  slight  headache;  mild  sore  throat;  pains  in  the 
back  and  legs;  little  or  no  coryza;  swollen  cervical  and  post- 
auricular  glands,  macular  rose-red  eruption  on  the  throat  con- 
stantly present;  and  the  eruption  of  a  dermal  rash  appearing  upon 
the  first,  or  rarely,  on  the  fourth  day.  This  consists  of  round  or 
oval,  slightly  raised,  pale  pinkish-red  pinhead  to  lentil-sized  mac- 
ules. These  are  discrete  at  first  and  afterwards  may  coalesce, 
especially  on  parts  where  pressure  is  exerted.  It  shows  first  upon 
the  face,  follows  a  wave-like  progression  extending  to  the  body 
and  limbs  while  fading  upon  the  parts  first  affected  and  lasting 
in  one  region  from  a  few  hours  to  a  half  day.  It  extends  over  the 
whole  body  within  twenty-four  hours. 

There  is  usually  more  or  less  itching.  The  rash  may  be  the 
first  symptom  of  disease  noticed.  After  persisting  for  two  or 
three  days,  the  fever  and  eruption  gradually  subside  together.  The 
skin  is  slightly  discolored,  and  slight  desquamation  is  found. 

Two  varieties  are  described — the  scarletiniform  resembles  scar- 
let fever  but  is  much  milder;  the  morbilliform  resembles  measles. 

The  complications  and  sequelae  are  rare ;  bronchitis,  pneumonia, 
otitis  media,  and  very  rarely  a  false  membrane  on  the  throat  may 
be  found.. 

Treatment.  The  patient  should  be  kept  in  a  properly  heated 
and  ventilated  room,  and  in  bed  for  about  two  days.  The  main 
treatment  is  to  the  lesions  found,  if  any,  with  careful  treatment 
of  the  cervical  lymphatics,  general  relaxation  of  muscles  and  free- 
ing of  the  excretory  channels.    Such  measures  are  usually  sufficient. 

The  diet  should  be  reduced  and  regulated  according  to  the  age 
of  the  patient  and  the  severity  of  the  symptoms.  Free  bowel 
movement  must  be  secured.  Tepid  sponging  once  daily  followed 
by  an  oily  application  on  the  itching  parts  is  agreeable.  Heat  may 
be  applied  to  the  enlarged  posterior  cervical  glands  with  relief. 

Prognosis.  Recovery  is  the  rule.  Relapses  are  more  severe 
than  the  primary  attack.  They  are  prevented  by  good  nursing. 
In  unhygienic  surroundings  or  if  the  child  is  delicate  the  outlook 
is  more  serious.    Recurrences  do  not  occur  and  sequelae  are  absent. 

Prophylaxis.  The  patient  should  be  isolated  for  ten  days  after 
the  appearance  of  the  rash. 

Like  measles,  this  disease  seems  to  lower  the  general  resistance 
to  other  infections.  For  this  reason,  children  recovering  from  this 
mild  disease  should  receive  especial  care  to  protect  them  from 
other  infectious  diseases,  and  also  to  protect  them  from  cold.  Even 
more  than  under  ordinary  conditions,  such  children  should  be 
given  plenty  of  fresh  air,  good  food  and  suitable  exercises. 


562  DISEASES  DUE  TO  UNKNOWN  AGENTS 

EPIDEMIC  PAROTITIS 

(Epidemic  parotiditis;  mumps) 

Epidemic  parotitis  is  an  acute,  specific,  infectious,  contagious 
inflammation  of  the  parotid  and  other  salivary  glands,  characterized 
by  pain,  swelling,  fever  of  a  moderate  degree  and  disordered  func- 
tion.   There  is  a  special  liability  to  orchitis  or  to  mastitis. 

Etiology.  The  infecting  agent  probably  enters  through  the  ex- 
cretory duct  producing  a  catarrhal  inflammation  which  rapidly 
extends  into  the  interstitial  tissues  of  the  glands  rather  than  the 
parenchymatous  tissue.  Congestion,  swelling  and  infiltration  with 
serous  fluid  take  place  with  more  or  less  infiltration  of  the  adjacent 
connective  tissues.    The  process  rarely  goes  on  to  suppuration. 

The  disease  occurs  both  epidemically  and  sporadically,  with 
an  incubation  period  of  two  to  three  weeks  and  on  recovery 
usually  conferring  immunity  although  a  second  and  a  third  attack 
have  been  known.  Children  between  the  ages  of  five  and  sixteen 
years  are  the  most  liable  to  the  infection.  Upper  cervical  lesiqns 
especially  those  of  the  atlas  and  axis  are  predisposing  factors. 

Diagnosis.  Except  in  sporadic  cases,  there  is  usually  a  history 
of  the  disease  in  the  family  or  in  the  neighborhood. 

The  invasion  is  rather  sudden,  with  moderate  fever  usually 
below  102°  F.  with  its  attendant  phenomena,  dull  pain  and  tension 
in  front  of  the  ear  on  one  side,  and  stiffness  at  the  angle  of  the 
inferior  maxillary.  Swelling  appears  which  gradually  increases  until 
within  forty-eight  hours  the  whole  cheek  and  neck  is  greatly 
enlarged,  the  face  distorted  and  the  lobe  of  the  ear  displaced  by 
the  infiltration  beneath  the  sternomastoid  muscle.  If  only  one 
gland  is  involved  at  first,  the  second  usually  follows  in  a  day  or 
so  although  often  in  a  lesser  degree.  The  patient  is  unable  to 
open  his  mouth  without  pain;  acids  or  rarely  sweets  produce 
spasm  of  the  jaw  muscles;  speech  and  even  deglutition  are  diffi- 
cult. The  saliva  is  sometimes  increased  and  at  other  times  dimin- 
ished. Salivation  is  frequent.  The  breath  is  foul  and  the  tongue 
is  furred.  The  submaxillary  and  the  sublingual  glands  may  en- 
large also. 

There  is  usually  no  change  in  the  color  of  the  skin  covering 
the  gland.  The  mucous  membranes  of  the  cheek  and  pharynx  are 
reddened  and  there  may  be  a  slight  angina.  The  tumor  feels  hard 
and  doughy,  not  fluctuant,  and  is  somewhat  sensitive  to  pressure. 

The  spine  often  shows  subluxations  in  the  cervical  region 
especially  of  the  atlas  and  axis,  perhaps  upper  rib  lesions  also.  If 
the  submaxillary  gland  is  involved,  the  second  and  third  dorsal 
vertebrae  with  their  ribs  may  show  maladjustment.  These  lesions 
may  be  secondary. 


EPIDEMIC  PAROTITIS  563 

The  symptoms  persist  for  six  to  fourteen  days,  when  the  swell- 
ing diminishes  and  the  patient  rapidly  recovers  his  health  and 
strength. 

If  the  temperature  does  not  fall  when  the  parotid  symptoms 
decline  some  other  involvement  may  be  looked  for — orchitis  in  the 
male,  and  mastitis,  ovaritis  or  vaginitis  in  the  female.  This  does 
not  occur  before  puberty.  When  orchitis  does  occur,  it  is  uni- 
lateral, increases  for  three  or  four  days,  and  is  usually  followed 
by  resolution.     In  severe  cases  atrophy  may  occur. 

Treatment.  The  patient  must  be  kept  in  a  well-lighted,  well- 
ventilated,  evenly  warmed  room,  away  from  other  children ;  in  bed 
if  the  temperature  indicates. 

The  correction  of  all  bony  lesions  found  is  indicated,  paying 
particular  attention  to  the  cervical  region  especially  the  atlas  and 
axis.  The  second  and  third  dorsal  vertebrae  need  attention  from 
the  influence  of  those  nerves  on  the  submaxillary  glands.  Upper 
rib  lesions  must  be  searched  for  also. 

A  liquid  diet  of  fruit  juices  with  water,  thin  gruels,  milk  and 
plenty  of  water  is  indicated. 

The  bowels  and  other  excretory  organs  must  be  kept  freely 
active.  Tepid  sponging  allays  the  fever  restlessness  and  keeps  the 
skin  active.  The  treatment  making  the  patient  the  most  comfort- 
able is  the  relaxation  of  the  deep  muscles  of  the  neck  and  shoulders 
and  those  under  the  angle  of  the  jaw  as  well  as  relaxing  contracted 
muscles  wherever  found.  The  very  gentle  relaxing  of  the  tissues 
around  the  gland  itself  by  crowding  them  toward  the  gland  assists 
in  relieving  the  tension  by  securing  a  better  venous  and  lymphatic 
drainage. 

Inhibition  of  the  upper  posterior  cervical  nerves  by  a  few 
minutes'  steady  pressure  assists  in  lowering  the  temperature. 
Raising  and  spreading  the  ribs  from  the  second  to  the  seventh 
gives  relief. 

Hot  applications  to  the  swollen  gland  are  very  soothing.,  and 
may  consist  of  hot  fomentations,  a  hot  salt  bag,  cotton  wadding 
covered  with  oiled  silk,  or  a  hot  water  bottle. 

A  mild  antiseptic  mouth  wash  keeps  the  mouth  in  good  condi- 
tion. 

Orchitis  should  not  occur  if  the  boy  is  kept  warm  and  in  bed. 
If  it  does,  the  best  treatment  is  rest,  support  and  protection  with 
cotton  wool,  cold  applications  and  the  correction  of  any  bony  or 
muscular  lesions"  affecting  the  pelvic  viscera.  Good  drainage  is 
best  secured  by  support  and  manipulation. 

Mastitis  may  occur,  especially  in  girls  nearing  puberty.  Rib 
lesions  have  been  found  present,  and  were  considered  responsible 
in  a  few  cases.  The  treatment  should  include  the  correction  of 
such  lesions  if  this  can  be  done  without  irritation  to  the  inflamed 


564  DISEASES  DUB  TO  UNKNOWN  AGENTS 

glands;  the  manipulation  of  neighboring  tissues,  with  very  gentle 
crowding  of  the  normal  tissue  toward  the  inflamed  glands,  without 
exerting  any  pressure  upon  the  gland  itself,  is  usually  helpful  and 
comfortable.    Free  tissues  back  to  axillary  lymphatics. 

Prognosis.  The  outlook  for  recovery  is  favorable.  The  disease 
usually  confers  immunity. 

If  the  child  has  been  kept  clean  and  warm  and  had  the  proper 
care  there  should  be  no  complications  nor  sequelae.  In  the  rare 
fatal  cases,  meningitis  is  the  usual  cause  of  death. 

Rarely  after  very  severe  cases,  permanent  deafness  has  resulted 
from  otitis  media  or  interna.  Sometimes  a  nonpurulent  arthritis 
results.  Chronic  hypertrophy  has  been  known.  All  of  these  cases 
were  probably  due  to  either  an  increased  virulence  or  to  bad 
hygiene. 

Under  osteopathic  care  the  duration  of  the  swelling,  fever  and 
pain  has  been  markedly  diminished. 

Prophylaxis.  Isolation,  disinfection  of  the  secretions  of  the 
upper  air  passages  and  a  quarantine  of  twenty-four  days  is  neces- 
sary. 

Children  should  not  be  allowed  to  be  exposed  to  this,  nor  to 
other  contagious  diseases.  Each  attack  of  any  contagion  is  that 
much  of  sickness  that  ought  to  be  avoided.  It  is  not  only  the 
sickness  itself  that  is  to  be  avoided,  but  also  the  diminished  vital- 
ity which  follows  recovery,  and  also  the  increased  susceptibility 
to  other,  perhaps  more  serious,  diseases  that  is  produced  by  almost 
if  not  all  of  the  ordinary  "children's  diseases." 

GLANDULAR  FEVER 

Glandulat  fever  is  an  infectious,  sometimes  epidemic  disease 
of  thildren,  characterized  By  swelling  and  tenderness  of  the  cer- 
vical lymphatics  accompanied  by  high  fever,  and  slight  angina  of 
the  throat. 

Etiology.  Children  between  7  months  and  13  years,  usually 
between  5  and  8  years,  are  predisposed.    Rarely  adults  are  affected. 

Diagnosis.  The  onset  is  abrupt  with  pain  in  moving  the  head 
and  neck,  perhaps  with  nausea  and  vomiting  and  abdominal  pain, 
temperature  101°  to  103"  F.  of  short  duration,  anginal  symptoms 
are  slight.  On  the  second  or  third  day,  the  characteristic  tender 
glandular  swellings  appear, -the  carotid  glands  most  frequently, 
the  postcervical,  next,  axillary  and  inguinal,  and  occasionally  the 
tracheo-bronchial  and  mesenteric  glands ;  the  size  varies  from 
that  of  a  pea  to  that  of  a  goose  tgg.  The  nodes  are  painful  to 
the  touch  but  the  skin  covering  them  is  not  involved.  The  sub- 
cutaneous tissues  of  the  neck  may  be  somewhat  edematous  and 
there  may  be  a  little  difficulty  in  swallowing.    The  swellings  per- 


GLANDULAR  FEVER  565 

sist  for  from  ten  days  to  three  weeks.  Complications  are  rare 
but  suppuration  has  occurred,  otitis  media,  retropharyngeal  abscess 
and  hemorrhagic  nephritis  also  occur  rarely.  The  liver  and  spleen 
may  be  enlarged. 

The  treatment  for  infections  in  general  must  be  modified  to  suit 
conditions  as  found.  Usually  it  is  best  to  avoid  local  manipulation 
until  the  glands  have  become  free  from  fever  and  pain.  Careful 
and  vigorous  treatment  for  increasing  the  mobility  of  the  lower 
thoracic  spinal  column,  raising  the  lower  ribs,  and  such  treatment 
for  liver,  spleen,  kidneys  and  bowels  as  may  be  indicated  on  exam- 
ination should  be  given.  Very  careful  relief  of  tension  of  the 
tissues  of  the  neck  is  sometimes  indicated. 

During  the  fever,  the  appetite  is  diminished.  Fruit  juices  may 
be  given  freely ;  liquid  foods  may  be  given  if  the  child  becomes 
hungry.  The  usual  methods  of  lowering  the  fever  may  be  em- 
ployed. The  child  should  not  be  permitted  to  lie  upon  his  back, 
nor  to  remain  too  long  in  any  one  position.  Excitement  must  be- 
avoided,  in  order  to  prevent  the  tendency,  occasionally  found,  for 
cerebral  symptoms  to  appear. 

Prognosis.    Recovery  is  to  be  expected,  with  no  sequelae. 


CHAPTER  L 
TROPICAI^  DISEASES 

BERI-BERI 

(Epidemic  neuritis) 

Beri-beri  is  an  endemic  and  epidemic  form  of  multiple  neuritis 
of  unknown  origin,  occurring  in  tropical  and  subtropical  countries 
and  characterized  by  paralysis  and  dropsy. 

The  disease  is  almost  certainly  due  to  a  lack  of  vitamins  in  the 
food.  In  Japan  and  India,  an  exclusive,  diet  of  polished  rice  may 
be  responsible ;  in  other  countries,  other  foods  deficient  in  vitamins 
make  the  exclusive  diet.  Predisposing  causes  are  the  coun- 
tries of  Japan,  Malay  Archipelago,  Burma,  and  Brazil;  seaports 
of  other  countries  where  ships  from  these  countries  call ;  over- 
crowding, warmth,  moisture  and  insanitary  surroundings. 

Inflammatory  and  degenerative  changes  are  found  in  the  axis 
cylinders  and  medullary  sheaths  of  the  peripheral  nerves.  In 
acute  cases,  the  phrenic  and  vagus  nerves  suffer.  Wasting,  degen- 
eration of  muscular  fibers,  both  voluntary  and  cardiac  are  present. 
In  the  "wet"  form,  edema  and  dropsy  of  the  body  cavities  occur. 

Rudimentary  types  are  those  in  which  paresis  and  paresthesia 
are  present,  dropsy  is  slight  or  absent,  cardiac  symptoms  are 
trifling.  The  attacks  may  persist  for  months  and  recur  with  each 
warm  season. 

The  acute  pernicious  or  cardiac  type  is  marked  by  symptoms  of 
acute  heart  failure  and  ends  in  death,  sometimes  in  a  few  hours 
cr  usually  in  a  few  weeks. 

Epidemic  dropsy  is  an  afifection  endemic  in  India,  resembling 
beri-beri  closely  and  distinguished  by  fever,  and  a  multiform  erup- 
tion upon  the  face,  body  and  limbs. 

Treatment.  Attention  to  the  diet  is  important.  Nitrogenous 
foods  and  the  raw  green  vegetables  should  be  freely  given.  Cer- 
tain extracts  from  yeast  contain  the  vitamins  in  a  good  form  for 
immediate  use. 

Prognosis.  Recovery  is  dependent  upon  the  form  of  the  dis- 
ease and  the  celerity  with  which  dietetic  and  sanitary  conditions 
are  corrected. 

ACUTE  FEBRILE  ICTERUS 

(Weil's  disease;  infectious  jaundice;  Feidler's  disease) 
Acute  febrile  icterus  is  a  disease  of  Eg>'pt,  the  tropics,  and 
other  climates  in  hot  weather,  of  unknown  origin,  occurring  spo- 

566 


BBRI-BBRI  567 

radically  and  endemically ;  and  characterized  clinically  by  sudden 
onset  with  chill,  remittent  fever  which  tends  to  decline  by  lysis  after 
a  week  or  two,  gastric  symptoms,  diarrhea,  muscular  pains  and 
headache.  On  the  third  or  fourth  day  a  jaundice  of  varying  in- 
tensity develops  with  prominent  nervous  symptoms  and  emaciation  ; 
delirium  and  coma  in  grave  cases,  with  epistaxis,  hematuria,  and 
albuminuria. 

It  is  most  common  in  butchers,  and  in  those  who  work  in  foul 
water  or  in  sewage.  Bacillus  proteus  vulgaris  may  be  the  infec- 
tious agent.     (See  also  page  528.) 

Treatment.  The  treatment  must  be  chiefly  symptomatic.  Im- 
proved sanitary  and  dietetic  conditions  are  important.  Free  drink- 
ing of  pure  water,  with  nutritious  diet  after  convalescence  is 
established  promotes  return  of  strength.  Treatment  to  secure  good 
circulation  through  the  liver  and  intestinal  tract  is  indicated. 

Prognosis.  Recovery  is  to  be  expected  in  about  a  month  with 
a  slow  convalescence. 

TROPICAL  SLOUGHING  PHAGEDENA 

This  is  a  disease  of  unknown  origin  which  is  marked  by  the  appearance 
of  a  blister  upon  an  extremity,  which  ruptures  after  a  few  hours,  exposing  a 
gray  area  of  superficial  gangrene  tending  to  spread  at  the  margins,  the  floor 
of  which  is  of  a  dirty  yellow  color,  and  the  odor  extremely  offensive;  the 
systemic  disturbance  is  slight.  After  a  variable  period,  usually  a  week,  the 
slough  separates  and  heals  without  much  damage  to  the  deepef  tissues. 

SPRUE 

(Psilosis) 

Sprue  is  a  tropical  disease,  and  is  found  in  this  country  in  those  who  have 
been  for  some  time  resident  in  the  tropics,  especially  in  India,  Japan,  or 
China.  It  is  a  chronic  or  remitting  inflammation  of  the  intestine,  probably 
microbic  or  parasitic,  characterized  by  irregular  bowel  action,  and  the  passage 
of  copious,  pale  drab  stools,  yeasty  and  of  sickly  odor.  Ulcerative  stomatitis 
and  anal  sores  are  frequent.  Constitutional  weakness,  irritability  of  temper, 
and  loss  of  memory  are  common  symptoms. 

The  mucous  membrane  of  the  intestines  shows  catarrhal,  ulcerative  and 
cirrhotic  changes  in  varying  severity. 

No  cases  have  been  reported  under  osteopathic  care. '  The  treatment  ordi- 
narily recommended  is  hygienic  and  dietetic — rest,  the  milk  diet,  and  freedom 
from  nervous  disturbances  give  the  best  results.    The  prognosis  is  doubtful. 

MADURA  FOOT 

(Mycetoma;  fungus  foot  of  India;  Pied  de  Cochin) 

Madura  foot  occurs  throughout  the  tropics,  endemic  in  India,  and  lately 
in  Panama.  It  is  caused  by  one  or  several  of  eleven  or  more  varieties  of 
streptothrix  and  related  fungi.  These  enter  the  foot,  rarely  other  parts, 
through  an  abrasion.  Small  round  painless  nodular  swelling  appears  on 
the  plantar  or  dorsal  surface  of  the  foot.     After  some  months,  these  gradually 


568  TROPICAL  DISEASES 

soften,  leaving  crater-like  openings  from  which  an  oily,  seropurulent  mate- 
rial is  discharged  containing  pinkish  granular  bodies  (pale  madura)  or  black 
granules  like  gunpowder  (melanoid  madura).  Other  nodules  form  on  the 
skin  and  break  down,  while  the  deeper  structures  undergo  degenerative  changes 
until  finally  the  diseased  part  becomes  badly  deformed,  and  the  limb  above  wastes 
away,  while  the  foot  doubles  in  size  and  loses  its  natural  contour.  Systemic 
symptoms,  except  those  due  to  a  long-continued  suppuration,  are  lacking. 

Treatment.  Amputation  is  the  only  treatment.  Good  shoes  and  cleanli- 
ness are  the  best  preventives. 

AINHUM 

Ainhum  (Dactylolysis  spontanea)  is  an  endemic  disease  of  India,  marked 
clinically  by  a  very  slow,  painless,  spontaneous  amputation  of  one  or  more  toes 
at  the  plantar  fold,  the  little  toe  being  the  most  frequently  affected.  Constitu- 
tional symptoms  are  absent.    The  disease  lasts  one  to  ten  years. 

GOUNDON 

Goundou  or  big-nose  is  an  African  disease  affecting  mainly  negro  children 
and  young  adults,  ushered  in  with  headaches,  hard  symmetrical  tumors  slowly 
developing  on  the  upper  part  of  the  nose,  with  fever  and  a  purulent  nasal  dis- 
charge. After  a  few  months,  all  constitutional  symptoms  subside  but- the  tumors 
are  permanent. 

MILIARY  FEVER 

(Sweating  sickness) 

Miliary  fever  is  an  infectious  disease  occurring  in  epidemics, 
mainly  in  France  and  Italy,  of  unknown  cause,  and  characterized 
by  moderate  "fever,  very  profuse  sweating,  tenderness  and  sense  of 
oppression  in  the  epigastrium,  on  the  third  or  fourth  day  the 
eruption  of  small,  reddish  macules  in  the  center  of  which  a  vesicle 
appears,  these  followed  by  a  scaly  desquamation.  The  eruption 
is  usually  most  profuse  upon  the  neck  and  trunk. 

In  severe  cases  high  fever,  delirium,  hemorrhage  and  extreme 
prostration  or  collapse  may  terminate  in  death. 

Treatment.    The  treatment  is  that  of  acute  infections,  (q.  v.) 

YAWS 

(Frambcesia  tropica) 

Yaws  is  a  chronic  infectious  tropical  disease  caused  by  the 
spirocheta  pertensis  (treponema  pertenue).  It  is  highly  contagious 
through  skin  abrasions  or  wounds,  has  an  incubation  period  of 
two  weeks  to  two  months,  and  is  characterized  clinically  by  the 
formation  of  peculiar  somewhat  raspberry-like  granulomata. 
There  is  a  week  or  so  of  prodromal  malaise  and  sometimes  fever, 
followed  by  the  appearance  of  the  eruption  which  at  first  consists 
of  minute,  itchy,  subcutaneous  papules  which  rapidly  increase  in 
size  and  protrude  through  the  skin.  The  apex  becomes  yellowish 
and  necrotic  and  later  necrotic  points  may  be  seen  around  it.    A 


DYSBNTBRY  569 

yellowish  offensive  oozing  occurs  which  drying  forms  the  crust. 
After  a  week  the  crust  falls  and  healing  takes  place  or  ulceration 
occurs.  The  lesions  are  painless  and  occur  in  successive  crops, 
thus  making  the  disease  last  for  months  or  years. 

Treatment.  The  infectious  organism  greatly  resembles  that 
of  syphilis,  and  the  skin  lesions  bear  certain  resemblances  to 
skin  syphilis;  the  treatment  employed  for  syphilis  of  the  skin 
should  be  tried.  The  Wassermann  reaction  is  positive,  and  the 
usual  medical  treatment  is  salvarsan. 

Prognosis.  Recovery  usually  occurs,  after  weeks  or  months 
of  successive  crops  of  the  lesions.  Children  may  die ;  older  persons 
who  are  weakened,  either  by  this  or  another  disease,  may  die 
from  exhaustion  or  mild  intercurrent  disease. 

Prophylaxis.  Isolation  of  patients  is  impossible  in  many  trop- 
ical countries.  Cleanliness  must  be  constantly  maintained  scru- 
pulously by  those  who  travel  in  countries,  or  who  are  associated 
with  persons  newly  arrived  from  the  countries,  in  which  the  dis- 
ease exists. 

Gangosa  is  an  ulceration  of  the  palate,  later  involving  the  bones 
and  cartilages  of  the  nose ;  less  often  the  eyes  are  also  destroyed. 
The  deformity  is  great;  death  is  not  expected.  The  disease  lasts 
from  several  months  to  three  years.  Wassermann  is  positive ;  the 
usual  medical  treatment  is  that  of  syphilis  (salvarsan),  and  there 
is  some  reason  for  considering  the  disease  a  tertiary  stage  of  yaws. 

TROPICAL  DYSENTERY 

(Bacillary  dysentery) 

Bacillary  dysentery  is  an  intestinal  disease,  usually  acute, 
caused  by  the  bacillus  dysenterise,  and  marked  by  an  inflammation 
of  the  colon,  fever,  and  other  general  symptoms. 

Etiology.  The  exciting  causes  are  the  dysentery  group  of 
bacilli,  including  the  Flexner-Harris  group,  the  bacillus  dysenterise 
of  Shiga  and  the  bacillus  Y  of  Hiss  and  Russell.  The  predisposing 
causes  are  hot  weather  and  defective  sanitation,  especially  in 
camps.  The  infection  is  conveyed  by  feces,  soiled  clothing, 
flies,  and  by  contaminated  soil  and  water.  Convalescents  may  act 
as  "carriers"  of  the  disease. 

Diagnosis.  The  incubation  period  is  from  two  to  eight  days. 
In  the  acute  form  the  onset  is  usually  sudden  or  a  previous  slight 
diarrhea  may  have  been  present.  There  are  frequent  or  incessant 
calls  to  stool  with  pain  in  abdomen,  griping  (tormina)  and  tenes- 
mus. The  stools  are  small,  composed  of  a  slimy  mucus  which 
within  twenty-four  hours  becomes  blood-stained.    The  passage  of 


570  TROPICAL  DISEASES 

a  stool  gives  no  relief ;  straining  continues,  and  in  grave  cases  from 
50  to  200  stools  in  twenty-four  hours  occur.  The  constitutional 
reaction  is  marked  by  a  slight  or  moderate  fever  103°  to  104°  F., 
pulse  small  and  frequent,  great  thirst,  tongue  dirty,  white-furred ; 
dizziness,  dry  skin,  and  the  patient  seriously  ill  within  forty-eight 
hours.  In  milder  cases,  the  urgency  of  the  symptoms  abates,  the 
stools  lessen,  temperature  falls,  and  within  two.  or  three  weeks  the 
patient  is  convalescent.  In  the  graver  cases,  the  patient  may  die 
of  exhaustion,  or  the  condition  may  rapidly  assume  a  low  and 
typhoid  state,  or  death  may  result  from  4)yemia  or  perforation. 
In  fatal  cases  death  usually  occurs  on  the  third  or  fourth  days. 
The  sub-acute  or  chronic  form  lasts  weeks  or  years,  the  patient 
becoming  much  emaciated  and  having  three  to  five  stools  in  twen- 
ty-four hours,  partly  fecal,  much  mixed  with  mucus,  occasionally 
with  blood,  and  sometimes  appearing  like  "frog's  spawn."  The 
appetite  is  poor,  the  tongue  red  and  glazed,  the  anemia  and  emacia- 
tion progressive,  and  the  patient  has  a  shrunken  and  cachectic 
appearance.    The  spleen  is  not  enlarged. 

The  complications  include  peritonitis,  pleurisy,  pericarditis,  en- 
docarditis, arthritis,  rarely  pyemia,  anemia,  and  dropsy.  Malaria 
and  bacillary  dysentery  may  coexist.  Persistent  dyspepsia  and 
irritability  of  the  bowels  may  follow. 

The  blood  of  a  patient  infected  with  an  organism  of  the  Flex- 
ner-Harris  type  will  agglutinate  a  pure  culture  of  the  organism  in 
a  dilution  of  1:1000  to  1500.  In  the  case  of  the  Shiga  bacillus, 
agglutination  is  less  complete. 

A  lesion,  which  may  be  either  primary  or  secondary,  is  usually 
found  at  the  third  lumbar  and  should  be  immediately  corrected. 
This  will  often  subdue  the  pain  and  tenesmus.  Careful  relaxation 
of  the  sacral  muscles  followed  by  deep  steady  pressure  over  the 
third  and  fourth  sacral  foramina  will  give  some  relief.  Hot  fomen- 
tations may  be  used  over  the  abdomen.  The  patient  must  stay  in 
t^ed  and  be  very  quiet.  The  diet  must  be  fluid  at  first,  consisting 
of  milk,  egg-albumen,  barley  water,  and  chicken  broth,  etc.  During 
the  chronic  form,  the  diet  must  suit  the  case,  mainly  liquids  or 
semi-solid. 

Prophylaxis.  The  stools  should  be  disinfected  as  soon  as  voided. 
Good  sanitation  prevents  the  disease. 


DENGUE 

(Break-bone,  neuralgic,  dandy,  or  broken-wing  fever) 
Dengue  is  an  acute,  epidemic,  infectious,  febrile  disease  of  trop- 
ical and  subtropical  regions,  attended  by  two  febrile  paroxysms, 
the  first  characterized  by  high  fever,  severe  and  shifting  pains  in 
the   muscles   and   joints   and   an   erythematous,  rash,   the    second 


DENGUE  571 

paroxysm  by  milder  fever,  intense  itching,  polymorphous  rash  and 
disproportionate  debility. 

Dengue  occurs  sporadically,  epidemically  and  pandemically, 
attacking  persons  of  all  ages  and  classes.  Epidemics  spread  with 
great  rapidity  and  suddenness.  The  agent  is  communicated  by 
inoculation  of  infected  blood  or  by  bites  of  mosquitoes  of  varieties 
Culex  fagitans  and  Stegomyia  fasciata.  The  organism  is  not  def- 
initely known.  The  incubation  period  is  from  two  to  five  days. 
There  are  no  characteristic  morbid  changes  and  it  is  rarely  fatal. 

Diagnosis.  The  symptoms  set  in  abruptly  with  chilliness,  intense 
headache,  backache,  severe  pains  in  a  single  joint  often  extending 
rapidly  to  all  the  joints  and  bones  and  shifting  from  one  to  another; 
soreness  at  the  seat  of  pain,  particularly  if  in  the  head  or  eyeballs ; 
temperature  gradually  rising  to  103°  to  105°  F.,  even  to  106°  to 
107°  F.,  accompanied  by  slight  nocturnal  delirium ;  pulse  rapid  and 
full,  respirations  quickened;  suffused  bloated  face  with  injected 
conjunctivae;  sore  throat,  thickly  coated  tongue;  anorexia,  marked 
thirst,  nausea,  vomiting  and  constipation,  and  a  general  erythema- 
tous rash.  The  painful  joints  may  be  red  and  swollen,  or  without 
much  redness  or  swelling.  After  one  to  four  days,  the  rash  and 
fever  subside,  leaving  the  patient  prostrated  and  stiff.  After  a  re- 
mission of  two  to  four  days,  there  is  a  sudden  milder  return  of 
fever,  more  pains,  intense  itching  and  a  macular,  rubeolar  or  vesic- 
ular rash,  appearing  first  upon  the  palms  and  spreading  over  the 
arms,  face,  trunk,  and  lower  limbs.  This  rash  remains  about  two 
days,  when  it  slowly  fades  and  desquamates.  The  other  symptoms 
disappear  within  eight  days  of  the  onset,  but  the  patient  is  left  in 
a  state  of  mental  and  physical  prostration  disproportionate  to  the 
severity  of  the  primary  attack.  The  pains,  especially  those  of  the 
smaller  joints,  may  persist  for  a  long  time  so  that  the  gait  of  a 
convalescent  is  stiff  and  affected. 

The  chief  complications  are  insomnia,  convulsions  in  children, 
and  hemorrhages  from  mucous  surfaces. 

Sequelae  are  few  although  atrophy  of  the  muscles  has  occurred. 

The  spinal  examination  shows  the  cervical  and  lumbar  regions 
to  be  more  affected  on  the  second  day,  while  the  lower  dorsal  seems 
to  be  worse  on  the  third. 

Treatment.  Put  the  patient  to  bed  in  a  suitable  room  protected 
from  mosquitoes.  Early  treatment  is  important.  Vigorous  treat- 
ment of  the  sub-occipital,  upper  and  lower  dorsal  and  lower  lum- 
bar regions  controls  the  large  vascular  areas  of  the  lungs,  the 
splanchnic  region,  and  the  lower  limbs.  The  diet  should  consist 
of  liquids  and  much  water,  preferably  hot  during  the  fever,  or  of 
splinters  of  ice  in  the  mouth.  During  convalescence,  the  diet  should 
be  carefully  regulated  and  nutritious. 


572  TROPICAL  DISEASES 

The  bowels  must  be  kept  active  with  as  little  disturbance  as 
possible  on  account  of  the  muscular  pain.  The  high  fever  is  best 
controlled  by  inhibition  of  the  posterior  cervical  areas,  tepid 
sponging  and  by  ice-cap  to  the  head.  The  pain  is  alleviated  by 
correction  of  parts  impinging  on  nerve  tissues  and  by  strong  in- 
hibition. A  short  hot  bath  or  a  continuous  warm  bath  may  give 
great  relief.  The  entire  spinal  structure  must  be  watched  during 
convalescence  when  the  object  is  to  secure  the  best  supply  of  blood 
to  every  part  of  the  body  through  good  food,  plenty  of  fresh  air, 
and  unimpeded  nerve  supply. 

Prognosis.  The  prognosis  is  favorable  for  recovery.  Relapses 
are  common  even  after  two  weeks  from  onset,  hence  the  most  care- 
ful nursing  is  necessary. 

The  disease  does  not  confer  immunity.  The  best  preventive 
is  to  kill  the  mosquitoes  in  the  territory  affected.  The  rare  sequelae 
are  prevented  by  carefulness  on  the  part  of  physician,  nurse  and 
patient. 

MALTA  FEVER 

(Mediterranean  fever;  rock  fever;  Neapolitan  fever;  undulant  fever) 
Malta  fever  is  an  acute,  endemic  fever  of  the  south  of  Europe, 
characterized  by  an  irregular  course,  undulatory  pyrexial  relapses, 
profuse  sweats,  rheumatic  pains,  and  an  enlarged  spleen. 

The  exciting  cause  is  the  micrococcus  melitensis.  The  predis- 
posing factors  are  lesions  of  the  skin  and  disturbed  circulation 
through  the  intestinal  tract.  Youthful  males  are  most  often  affected. 
The  disease  is  especially  frequent  at  Malta  and  Gibraltar.  The 
goats  of  the  district  are  largely  infected  and  their  milk  contains  the 
organism. 

Diagnosis.  Incubation  is  from  six  to  ten  days.  There  is  a 
marked  prodromal  period  with  chilliness,  lassitude,  and  general 
malaise,  then  a  gradual  rise  in  temperature  to  104°  F.  or  over,  fre- 
quently remittent.  Simultaneously,  enlargement  of  the  spleen  and 
drenching  sweats  are  accompanied  by  rheumatic  and  neuralgic 
pains,  and  constipation.  There  may  be  a  slight  cough  and  rales  at 
the  bases  of  the  lungs.  This  stage  may  last  from  one  to  three 
weeks.  The  first  period  of  apyrexia  lasts  a  few  days  usually,  and 
is  succeeded  by  a  relapse  of  several  weeks.  Another  remission 
comes  on  longer  than  the  first  to  be  again  followed  by  a  relapse. 
The  sweats  continue  and  the  patient  becomes  very  weak.  The 
main  complications  are  arthritis,  orchitis,  and  neuralgia. 

Blood.  Blood  serum  of  patients  affected  by  Malta  fever  shows 
agglutinating  properties  with  a  pure  culture  of  the  micrococcus 
melitensis,  even  upon  marked  dilution.    There  isjeucopenia. 


YELLOIV  FEVER  573 

Treatment.  The  treatment  is  generally  that  of  typhoid  fever. 
The  symptoms  are  to  be  treated  as  they  occur.  A  thorough  spinal 
treatment  with  correction  of  any  subluxated  vertebrae  or  other 
lesions  will  materially  lessen  the  number  of  relapses. 

Prognosis.  The  outlook  is  favorable  for  recovery.  The  mor- 
tality is  about  two  per  cent.  The  rare  malignant  cases  usually 
succumb. 

Prophylaxis.  Do  not  drink  goat's  milk  when  traveling  in  Med- 
iterranean countries.  Goats  brougl^t  to  this  country  should  be  free 
from  disease. 

YELLOW  FEVER 

(Yellow  jack;  bilious  malignant  fever;  typhus  icterode;  sailor's  fever;  black 

vomit) 

Yellow  fever  is  an  acute,  specific,  infectious  fever,  of  a  limited 
geographical  distribution;  characterized  by  jaundice,  albuminuria, 
and  a  tendency  to  hemorrhages,  particularly  from  the  stomach. 

Etiology.  The  disease  is  caused  by  a  specific  poison,  the  micro- 
organism of  which  is  unknown.  The  intermediate  host  of  this 
unknown  organism  is  the  mosquito,  Stegomyia  fasciata,  which 
communicates  the  poison  by  being  inoculated  with  the  blood  or 
serum  of  an  infected  person  in  the  first  three  days  of  the  disease, 
not  later.  From  ten  to  twelve  days  are  required  for  incubation  in 
the  mosquito  before  its  bite  transmits  infection,  and  from  four  to 
five  days  more  after  the  bite  before  the  symptoms  develop  in  man. 

The  predisposing  causes  are  a  tropical  climate,  the  warm 
months,  tropical  Atlantic  seaports,  and  filthy  insanitary  urban 
conditions.  One  attack  confers  immunity  as  long  as  the  subject 
remains  in  the  infected  section.    Frost  stops  the  epidemic. 

Bony  lesions  affecting  the  liver  and  renal  areas  and  the  vagi  are 
probably  predisposing  causes  and  are  constant  in  affected  persons. 

Pathology.  There  is  dissolution  of  the  red  blood  cells,  granular  degenera- 
tion and  areas  of  necrosis  in  the  viscera,  and  general  glandular  involvement. 
The  liver  shows  size  about  normal,  color  pale  yellow  with  hemorrhagic  spots, 
cells  atrophied,  with  fatty  degeneration.  The  kidney  is  in  a  state  of  glomerulo- 
nephritis, is  much  engorged,  with  cells  full  of  fatty  globules. 

The  stomach  mucosa  is  injected  and  ecchymosed,  coated  internally  with 
altered  blood.    "Black  vomit"  is  -found. 

Diagnosis.  The  disease  is  ushered  in  either  by  a  prodromal 
period  with  malaise,  headache,  and  anorexia,  or  suddenly  by  chill, 
high  fever,  104°  to  106°  F.,  with  pains  in  the  head,  limbs,  and  back. 
The  full  and  strong  pulse,  rapid  at  first,  but  later  slowing  with  a 
steady  or  rising  teriiperature,  is  characteristic.  The  tongue  is 
pointed,  red  at  the  tip  and  edges,  and  furred  in  the  middle.  The 
stomach  is  irritable,  and  there  may  be  simple  vomiting.  Albumi- 
nuria may  be  present  upon  the  first  day.    The  patients  are  restless, 


574  TROPICAL  DISEASES 

anxious  and  extremely  prostrated.     There  is  constipation  and  a 
characteristic  odor. 

This  stage  lasts  from  one  to  four  days.  Slight  jaundice  or  de- 
lirium may  appear.  The  fever  remits  to  100°  to  99°  F.,  and  symp- 
toms abate.  Crisis  or  a  short  lysis  and  recovery  follow,  or  after  a 
few  hours  the  third  stage  appears.  The  symptoms  return  in  an 
aggravated  form  followed  by  jaundice  of  a  lemon  yellow  to  dark 
orange  brown,  black  vomit,  at  first  watery,  but  later  mixed  with 
altered  blood  and  like  coffee  grounds ;  highly  albuminous  scanty 
urine,  or  suppression;  slowing* pulse  with  a  rising  temperature; 
hemorrhages  from  mucous  surfaces,  epistaxis,  hemorrhage  from 
the  bowel,  metrorrhagia  (pregnant  women  abort) ;  collapse, 
shrunken  features,  cold  surface,  irregular  respiration  and  sometimes 
death,  the  mind  remaining  clear  to  the  end.  Recovery  may  occur 
even  after- black  vomit  has  appeared.  The  mental  aspect  is  a  pe- 
culiar alertness  with  unmistakable  evidences  of  fear,  even  after  the 
most  serious  symptoms  have  appeared. 

The  red  blood  cells  are  approximately  normal ;  hemoglobin  from 
75  to  50  per  cent;  hemoglobinemia  is  recorded;  leucocytosis  may 
be  present. 

Treatment.  Put  the  patient  in  a  clean  room,  screened  and  well 
ventilated.  Kill  all  the  mosquitoes  within  it.  The  room  and  every- 
thing in  it  must  be  absolutely  clean. 

Thorough  work  upon  the  whole  spine  is  necessary.  Correct 
lesions  if  possible  before  the  third  stage  begins.  Specific  lesions 
have  been  found  at  the  eighth  dorsal  and  second  lumbar  vertebrae. 
Headache  is  treated  by  deep  steady  pressure  to  the  occipital 
nerves  and  by  the  ice  bag  to  the  head.  Irritability  of  the  stomach 
is  relieved  by  the  general  treatment  and  by  the  use  of  ice  in  the 
mouth.  The  patient  m«st  have  all  the  water  he  can  drink  without 
causing  vomiting.  Keep  the  skin,  kidneys,  and  bowels  active  by 
direct  treatment  and  by  baths.  The  fever  is  treated  as  usual,  by 
deep  steady  pressure  in  the  occipital  region,  and  in  the  lower 
dorsal  area.  Sponging  and  cool  baths  may  be  used.  Suppression 
of  the  urine  is  treated  by  work  over  the  kidneys,  to  the  renal 
splanchnics,  and  by  hot  baths  and  packs.  Enterocylsis  is  useful 
in  uremia.  During  the  period  of  depression,  the  heart  must  be 
carefully  noted  and  the  measures  used  to  prevent  any  complication 
or  failure.  Especial  attention  must  be  paid  to  the  third  dorsal 
and  to  the  occipito-atlantoid  articulation. 

During  the  acute  stage  the  patient  cannot  take  food.  Water 
or  ice  is  to  be  given  freely.  As  soon  as  convalescence  begins, 
milk  diluted  with  lime  water  or  peptonized  milk  may  be  slowly 
begun  at  regular  intervals  and  given  in  small  quantities.  Gradually 
increase  until  the  patient  is  taking  a  normal  diet. 


CHOLERA  575 

Prognosis.  The  disease  seldom  lasts  more  than  a  week. 
Unfavorable  symptoms  are  high  fever,  collapse,  black  vomit,  and 
suppression  of  the  urine.  Favorable  indications  are  moderate  fever, 
slight  jaundice,  arriple  flow  of  urine,  and  freedom  from  -hemor- 
rhages.   Alcoholics  and  those  exposed  to  hardships  are  apt  to  die. 

Prophylaxis.  The  spread  of  the  disease  must  be  prevented  by- 
screening  the  apartments  of  the  infected  and  the  healthy  and  by 
screening  the  cisterns,  and  draining  swamps  or  covering  them  with 
petroleum.  Those  who  work  in  a  fever  district  should  at  least 
spend  the  nights  away  from  town,  preferably  at  some  height  above 
the  sea-level. 

Quarantine  is  fourteen  days  after  exposure  or  recovery. 

CHOLERA 

(Epidemic   cholera;    Asiatic   cholera;    malignant   cholera;    spasmodic   cholera; 

cholera  infectiosa) 

Cholera  is  an  acute,  specific,  infectious  disease,  endemic  in 
India,  epidemic  elsewhere,  characterized  by  violent  vomiting, 
purging  of  peculiar  "rice-water"  stools,  severe  muscular  cramps, 
and  a  condition  of  prostration  followed  by  collapse  and  death  or 
a  reaction  subsequently  developing  into  the  typhoid  state,  or  re- 
covery. 

The  exciting  cause  is  the  comma  bacillus  of  Koch  (cholera 
vibriones  or  spirillum),  and  its  toxalbumin.  It  is  feebly  contagious, 
mainly  by  the  stools.  The  bacillus  may  be  conveyed  by  infected 
water,  milk,  vegetables  washed  in  contaminated  water,  or  flies. 

Predisposing  causes  are  uncleanliness,  gastric  and  intestinal 
catarrh,  the  eating  of  unripe  fruits  and  alcoholic  drinks.  One 
attack  does  not  afiford  protection  against  another.  Incubation  is 
from  three  to  five  days. 

Diagnosis.  Symptoms  differ  in  different  cases  and  different 
epidemics.  The  stage  of  invasion  may  last  from  a  few  hours  to 
a  week.  The  disease  begins  with  chilliness,  excessive  thirst,  white 
coated  tongue,  unpleasant  taste  in  the  mouth,  slight  abdominal 
pain,  weakness  and  diarrhea.  From  three  to  twelve  copious, 
watery,  fecal,  yellow,  alkaline  stools  are  passed  during  the  day, 
easily  voided  with  force  and  only  slight  pain.  The  stools  rapidly 
become  whey-like,  grayish-yellow  and  flocculent.  Occasionally  an 
erythematous  rash  is  present. 

During  the  stage  of  prostration  or  evacuative  stage  the  tem- 
perature is  subnormal  and  pulse  weak.  The  stools  rapidly  increase 
in  number,  and  are  voided  with  rushing  force.  These  consist  of  a 
quart  or  two  of  grayish  or  whitish  "rice-water"  fluid,  accompanied 
by  forcible  vomiting  first  of  the  contents  of  the  stomach  with  more 
or  less  bilious  matter  and  afterward  of  the  peculiar  "rice-water" 


576  TROPICAL  DISEASES 

fluid.  The  thirst  is  intense.  Muscular  cramps,  most  severe  in  the 
calves  of  the  legs,  occur  in  all  parts  of  the  body.  This  stage  lasts 
from  two  to  sixteen  hours.  The  stage  of  collapse  or  algid  stage 
follows.  The  stools,  vomiting,  and  cramps  continue.  The  appear- 
ance of  the  patient  becomes  frightful:  the  eyes  are  sunken,  and 
surrounded  by  black  rings;  nose  pinched  and  pointed;  cheeks  hol- 
low, lips  blue  (facies  cholerica)  ;  the  surface  is  cold  and  moist,  the 
skin  of  the  hands  and  fingers  has  a  sodden  appearance.  The  tem- 
perature rapidly  falls  to  even  78°  F.  beneath  tongue,  while  the 
rectal  is  102°  F.  or  more.  The  pulse  becomes  small  and  compressi- 
ble, 100  to  120,  barely  perceptible  at  the  wrist,  and  the  heart  beats 
scarcely  recognizable.  The  voice  is  weak  and  husky,  sepulchral 
(vox  cholerica). 

Later  the  purging  usually  ceases  but  vomiting  may  continue. 
The  tongue  and  breath  are  icy.  The  mind  is  clear  but  most  patients 
are  apathetic.  The  urine  is  markedly  diminished  and  albuminous. 
Complete  suppression,  coma  and  death  may  follow  within  a  few 
hours.  This  algid  state  or  cholera  asphyxia  usually  terminates  in 
death  in  three  or  not  more  than  twenty-four  hours,  but  may  be 
followed  by  the  stage  of  reaction.  This  lasts  a  few  hours,  during 
which  the  temperature  gradually  rises,  the  pulse  becomes  fuller 
and  stronger,  countenance  brighter,  the  stools  more  fecal,  thirst 
lessens,  and  increasing  urine  is  a  good  prognostic  sign.  The  patient 
either  enters  upon  a  slow  convalescence  of  several  weeks  or  the 
typhoid  state  develops,  prolonging  recovery  for  several  weeks  or 
postponing  death  (cholera  typhoid). 

•  Infectious  complications  may  arise  as  pneumonia,  enteritis,  re- 
currence of  severe  diarrhea  or  uremia  with  coma  and  death. 

Other  complications  are:  severe  bed-sores,  boils,  abscesses, 
ulcers  and  gangrene  of  the  extremities,  bronchitis,  pneumonia  and 
pleurisy,  suppurative  parotitis,-  nephritis,  corneal  ulcers,  profuse 
sweats,  cutaneous  eruptions.  A  tendency  to  diphtheritic  inflam- 
mations of  the  mucous  membranes  of  the  colon,  especially  of  the 
throat  and  genitalia,  may  appear.  Pregnant  women  always  abort. 
Painful  tetanic  spasms  of  the  flexor  muscles  of  the  hands,  forearms, 
legs  and  feet  may  occur  on  tenth  to  fifteenth  days  of  convalescence. 

Varieties  of  cholera  include  cholerine,  which  progresses  as  far 
as  the  beginning  of  the  collapse  state  when  recovery  begins; 
cholera  sicca,  in  which  death  occurs  before  the  diarrhea  begins; 
and  cholera  typhoid,  characterized  by  fever,  dry  brown  tongue, 
feeble  rapid  pulse,  delirium,  coma  and  death.  During  the  stage  of 
reaction  or  during  convalescence  there  may  be  erythematous,  mac- 
ular or  purpuric  eruptions. 

Blood  Pressure.  This  disease  has  probably  the  lowest  blood 
pressure  readings  of  any  infectious  disease.  The  blood  pressure  is 
a  valuable  guide  in  treatment  in  the  stage  of  collapse  and  in  com- 


CHOLERA  .  577 

bating  the  post-choleraic  uremia.  A  pressure  below  70  mm.  sys- 
tolic is  a  dangerous  symptom. 

The  urine  is  scanty  and  albuminous.  The  urea  is  slight,  grad- 
ually increasing  to  enormous  amount.  Desquamating  renal  cells, 
fatty  and  hyaline  casts  are  found.  Large  quantities  of  indoxyl  and 
sulphates  are  generally  associated  with  aromatic  substances. 

The  stools  are  of  low  specific  gravity,  with  much  water,  sodium 
chloride  and  mucin ;  are  alkaline  in  reaction,  and  with  a  sugar 
forming  ferment  almost  constantly  present.  The  flocculent  sedi- 
ment contains  epithelial  cells  and  leucocytes,  shreds  of  mucus,  the 
comma  bacillus  in  abundance,  other  bacteria,  and  sometimes  blood. 

Treatment.  Arrest  in  the  diarrheal  stage  is  often  rather  easy, 
but  in  the  stage  of  collapse  is  difficult.  As  soon  as  the  least  symp- 
tom of  diarrhea  occurs  (in  an  epidemic)  the  patient  is  put  to  bed. 
General  treatment  is  necessary  but  the  main  factor  is  to  secure  a 
normal  circulation  through  the  bowel  by  relieving  the  muscular 
contractions  and  adjusting  the  lumbar  vertebrae.  Thoroughly 
loosen  up  the  spine  from  the  lowest  tip  to  the  head. 

No  food  is  to  be  given  during  the  prostration  stage.  Bits  of  ice 
in  the  mouth  allay  thirst;  sometimes  small  quantities  of  hot  water 
are  more  comfortable.  During  the  reactive  stage,  food  must  be 
given  sparingly  but  often,  of  peptonized  milk,  milk  and  lime  water, 
or  gruels.  Vomiting  is  treated  by  the  general  work  and  by  deep 
steady  pressure  at  the  fourth  and  fifth  dorsal  vertebrae  on  the  right 
side.  Lavage  may  be  necessary.  Cramps  are  best  relieved  by 
friction  of  the  skin  over  the  afifected  muscles.  Fever  rarely  requires 
any  special  treatment. 

During  the  stage  of  collapse  heat  must  be  applied  externally 
by  hot  applications,  hot  bricks,  bottles,  or  hot  baths.  Quick, 
stimulating  movements  given  through  the  dorsal  area,  especially 
the  third  to  fifth,  increase  respiration  and  cardiac  action.  Hypo- 
dermocylsis,  enterocylsis  or  intravenous  injection  of  hot  saline  solu- 
tion may  be  necessary. 

Colonic  irrigation  has  been  used  with  some  success.  Use  one 
to  three  gallons  twice  daily  of  either  hot  soapy  water  or  one  per 
cent  salt  solution.  Introduce  a  soft  rubber  tube  through  the  rectum 
into  the  sigmoid,  and  if  possible  into  the  descending  colon.  Let 
the  water  flow  very  slowly. 

Prognosis.  The  mortality  is  20  to  85  per  cent.  Favorable  indi- 
cations are  gradual  development  of  the  disease ;  good  constitution 
and  health,  and  good  habits.  Unfavorable  indications  are  sudden 
severe  onset  in  the  very  young  or  very  old,  and  in  patients  addicted 
to  various  excesses,  and  amid  insanitary  surroundings. 

Prophylaxis.  Isolation  should  be  prompt.  Sterilization  of  all 
discharges  with  chloride  of  lime  or  carbolic  acid,  boiling  of  all  bed. 


578  .      TROPICAL  DISEASES 

table,  and  personal  linen  as  soon  after-use  as  possible  is  necessary. 
In  the  event  of  death,  wrap  the  patient  in  a  sheet  soaked  in  bichlo- 
ride of  mercury  1 :1000  solution.  Burial  must  be  speedy  and  private. 
Attendants  on  cholera  patients  should  avoid  direct  contact  with 
other  people ;  should  wash  their  hands  thoroughly  after  contact  with 
the  patient;  and  should  protect  hair,  clothing,  and  shoes  with  some 
covering  that  may  be  easily  discarded.  Non-infected  individuals 
in  a  cholera  district  should  be  instructed  to  use  none  but  boiled 
water  and  milk,  and  to  partake  of  light,  easily  digested  food  that 
has  been  kept  protected  from  contamination  by  flies  and  other 
insects. 

TROPICAL  LIVER 

(Active  congestion  of  the  liver,  active  hyperemia  of  the  liver) 

Tropical  liver  is  very  common  in  the  tropics.  It  is  due  to 
faulty  diet,  especially  overeating  of  protein  food,  abuse  of  alcohol, 
coffee  and  highly  seasoned  foods,  lack  of  exercise,  toxic  and  infec- 
tious processes.  It  is  characterized  by  a  sense  of  fullness  in  the 
right  hypochondrium,  disturbance  of  appetite  and  constipation. 
The  patient  is  irritable  and  depressed. 

The  quadratus  lumborum  and  the  mid-dorsal  muscles  are  rigid. 
The  ninth  and  tenth  ribs  are  approximated,  especially  on  the  right 
side.  Pain  in  the  back  in  the  region  of  the  seventh  and  eighth 
dorsal  and  under  the  shoulder  blade  may  be  very, severe. 

Treatment.  Correct  all  lesions  by  giving  vigorous  manipula- 
tions. Give  enema  if  necessary  to  cleanse  the  colon.  Allow  no 
food  for  a  day  or  two,  then  give  strict  cellulose  diet  for  at  least 
one  week.  To  prevent  recurrence  the  etiological  dietetic  errors 
should  be  avoided  and  a  suitable  amount  of  exercise  in  the  open 
air  provided.    In  severe  cases  a  change  of  climate  must  be  sought. 

The  disease  does  not  endanger  life  but  lowers  resistance  to 
infection  and  diminishes  efficiency  and  comfort. 

(See  also  Part  X,  Animal  Parasites.) 


PARTX 
DISEASES  DUE  TO  ANIMAL  PARASITES 


GENERAL  DISCUSSION 

The  human  body  seems  able  to  adapt  itself  to  the  presence  of 
animal  parasites,  but  only  rarely  to  develop  any  specific  toxin  in 
the  way  of  self-protection.  This  may  be  due,  in  part,  to  the  fact 
that  the  inflammations  set  up  by  animal  parasites  are  rarely  pro- 
found, but  are  either  very  slow  and  chronic,  or  are  absent  alto- 
gether. With  the  human  extravagance  in  regard  to  making  pro- 
vision, most  bodies  are  able  to  act  as  free  hotels  for  many,  or  for 
very  large  animal  parasites,  without  being  seriously  affected  by 
their  presence.  On  the  other  hand,  there  are  a  few  animal  parasites 
which  cause- very  serious,  even  fatal,  symptoms. 

In  order  to  facilitate  diagnosis,  the  follovi^ing  list  of  parasites  is 
prepared : 

The  Digestive  System. 

Salivary  glands — Echinococcus  cysts. 

Stomach  wall — Pentastomum  denticulatum  and  Echinococcus. 

Intestines — Tapeworms,  nearly  all  the  nematodes  and  Rhizopoda.     Almost 

any  parasite  may  be  an  inhabitant  of  the  intestines  at  some  time. 
Liver — Echinococcus;  Distomum  hepaticum;  Coccidia;  Pentastomum  dentic- 
ulatum; more  rarely — Cysticercus  cellulosa;  Ascaris  lumbricoides ;   Psoro- 

sperms. 

Urinary  System. 

Kidneys  and  Ureters — Filaria;  Distomum  hematobium;  Eustrongylus  gigas; 

Ascaris  lumbricoides. 
Bladder — Echinococcus;  Filaria;  Distomum;  Ova  of  Bilharzia. 
Urethra — Eustrongylus  gigas;  Thread-worms;  Larvae  of  certain  flies. 

Respiratory  System. 

Bronchi — Echinococcus ;  rarely  nematode  worms. 

Lungs — Echinococcus;    Cysticercus    cellulosa    rarely;    Strongjdus    longivag- 

inatus ;  Monas  ;  Cercomonas ;  Coccidia ;  Pentastomum  denticulatum ;  pso- 

rosperms;  Distomum  pulmonale. 
Pleurae — Echinococcus  and  Psorosperms. 
Medistinum — Echinococcus.   . 

Circulatory  System. 

Heart— Pericardium,    Cysticercus,    Echinococcus,    Trichina,    Pentastomum 

denticulatum. 
Myocardium — Echinococcus  and  Cysticercus. 
Lymphatic  vessels — Echinococcus  and  Filaria. 

Lymphatic  glands — Filaria,  Trichina,  Trypanosomes,  Echinococcus,  Cysticer- 
cus, Pentastomum  denticulatum. 
Blood. 

Malarial  organisms,  Filaria,  Piroplasma,  Trypanosomes. 

579 


580  ANIMAL  PARASITES 

Nervous  System. 

Brain — In  the  pia  and  arachnoid,  Echinococcus  and  Cysticercus  cellulosa. 

Cord,  the  spinal  dura — as  above. 

Retina — rarely  the  cysticercus. 

Vitreous  humour  of  the  eye — Filaria  and  Cysticercus. 

Genital  System. 

Prostate — Echinococcus. 

Scrotum — Filaria  and  Echinococcus. 

Membranes  of  the  testis — Filaria  and  Echinococcus. 

Vagina — Larvae  of  certain  flies;  Oxyuris  vermicularis;  Ascaris  lumbricoides ; 

Trichomonas  vaginalis. 
Uterus — Echinococcus. 
■  Ovaries — Echinococcus. 
Mammary  Gland — very  rare — Echinoc6ccus  and  cysticercus. 

Miscellaneous. 

.Spleen — Echinococcus;  Cysticercus;  Pentastomum  denticulatum. 

Pituitary  body — rarely  Echinococcus. 

Thyroid — rarely  Echinococcus. 

Bones — Echinococcus;  Cysticercus  cellulosa. 

Joints — Echinococcus. 

Nose — Larvae  of  certain  flies. 

External  ear — Larvae  of  certain  flies ;  Ascarus  foUiculorum. 

Muscles — Trichina. 

Skin — Hook-worm ;  Medina  worm. 


CHAPTER  LI 
PROTOZOAN  INFECTIONS 

MALARIAL  FEVER 

Malarial  fever  is  a  specific  infectious  disease  caused  by  the 
presence  in  the  blood  of  the  Plasmodium  malariae  and  presenting 
clinically  the  following  varieties:  (1)  periodically  recurring 
paroxysms  of  intermittent  fever;  (2)  continued  fever  with  well- 
marked  remissions;  (3)  certain  pernicious,  rapidly  fatal  forms; 
(4)  a  chronic  cachexia  with  anemia  and  enlarged  spleen. 

Etiology.  The  disease  is  caused  by  the  plasmodium  malariae 
or  hemamebse.  There  are  three  forms  exciting  disease  in  man 
as  follows:  plasmodium  malariae,  causing  the  quartan  form;  Plas- 
modium vivax,  the  tertian ;  and  the  plasmodium  precox  or  hema- 
mebse,  causing  the  estivo-autumnal  form.  The  disease  is  spread 
by,  the  bites  of  mosquitoes  of  the  genus  Anopheles  which  must 
themselves  have  been  infected.  Predisposing  factors  are  exposure 
at  night,  a  country  with  marshes,  humidity,  high  temperature,  ab- 
sence of  winds,  and  such  other  factors  as  favor  the  breeding  of 
mosquitoes.  Lesion  of  the  eighth  to  the  tenth  thoracic  vertebrae 
and  ribs  are  constant. 

The  parasites  are  found  in  the  red  blood  cells  during  paroxysms. 
The  enlargement  of  the  spleen  is  sometimes  very  great.  In  recent 
cases  the  organ  is  soft,  in  older  cases,  firm,  "ague  cake."  Conges- 
lion  of  the  liver  is  present.    Anemia  is  usually  marked. 

Types  of  Intermittency.  Tertian — When  one  group  of  tertian 
parasites  is  present,  the  paroxysms  recur  every  third  day;  when 
two  groups  are  present,  double  tertian  or  quotidian  type  is  present, 
with  chills  every  day.  This  is  the  most  common  type  in  the  north- 
ern and  middle  states. 

Quartan — When  one  group  is  present  of  quartan  parasites  the 
paroxysm  recurs  every  fourth  day;  when  two  groups,  it  occurs  for 
two  days  in  succession,  the  third  day  none;  when  three  groups  are 
present,  daily  paroxysms  occur. 

The  paroxysm  is  said  to  "anticipate"  when  it  comes  a  little 
earlier  each  succeeding  day;  and  to  "postpone"  when  it  comes  on 
a  little  later. 

Intermittent  Fever.  (Ordinary  ague.)  The  paroxysm  is  usually 
preceded  by  a  day  or  so  of  premonitory  symptoms.  The  typical 
attack  usually  consists  of  three  stages,  a  cold,  hot,  and  sweating. 

581 


582  PROTOZOAN  INFECTIONS. 

^  Cold  Stage — The  patient  shivers  violently,  the  teeth  chatter,  the 
skin  is  pale  and  cold,  and  the  papillae  are  raised  (goose  skin  or 
cutis  anserina),  nails  and  lips  are  blue,  the  face  anxious  and  the 
features  pinched.  There  are  often  vomiting,  thirst  and  hyperpnea. 
The  temperature  is  much  lowered  externally  but  raised  in  the 
mouth  and  rectum  to  102°  to  104°  F.  The  urine  is  pale,  copious, 
of  low  specific  gravity.  This  stage  lasts  from  a  few  minutes  to 
an  hour  or  more.  Towards  the  end  the  temperature  may  be  103° 
to  106°  F. 

Hot  Stage — There  is  a  gradual  or  sudden  onset.  The  skin  is 
hot,  red,  and  burning,  vomiting  is  increased,  the  carotids  throb 
forcibly;  headache  is  intense;  there  may  be  violent  delirium.  The 
temperature  is  often  106°  F.  or  more,  the  pulse  rapid  and  full,  and 
epistaxis  or  diarrhea  may  occur.  This  stage  lasts  from  one  to  many 
hours.  The  urine  is  scanty,  of  high  specific  gravity,  large  quantities 
of  urates  and  urea,  and  albuminuria  is  frequent. 

Sweating  Stage — The  sweating  commences  at  the  roots  of  the 
hair  and  soon  becomes  general  and  profuse.  The  pulse  is  softer, 
the  temperature  falls  gradually,  and  the  patient  is  restored  to  a 
normal  condition.  The  urine  is  of  high  specific  gravity,  scant  in 
quantity,  the  urates  are  more  abundant  than  urea.  This  stage 
usually  persists  from  two  to  four  hours  and  is  often  followed  by 
refreshing  sleep. 

Remittent  Fever.  (Bilious,  tropical,  marsh,  bilious  remittent, 
typho-malarial,  or  estivo-autumnal  fever).  This  form  is  associated 
with  the  estivo-autumnal  parasite,  and  is  especially  frequent  in 
the  tropics. '  It  may  be  seen  in  the  late  summer  and  autumn  in 
temperate  climates. 

The  type  is  either  definitely  intermittent  with  irregular  intervals 
between  the  paroxysms,  or  there  may  be  continuous  fever  with 
well-marked  remissions  but  no  intermissions. 

The  symptoms  common  to  both  types  are  coated  tongue,  epi- 
gastric pain,  anorexia,  bilious  vomiting,  constipation  or  diarrhea, 
jaundice,  a  moderate  cold  stage,  which  does  not  recur  with  each 
paroxysm,  an  intense  hot  stage  with  intense  headache  and  gastric 
irritation,  and  lastly  an  almost  imperceptible  sweating  stage  which 
may  be  absent.  Either  type  tends  to  merge  either  into  an  ordinary 
intermittent  attack  or  into  a  typhoid  state  of  grave  prognosis.  As 
a  rule,  this  fever  lasts  from  seven  to  fourteen  days.  Both  remittent 
and  the  regular  intermittent  type  tend  to  spontaneous  improvement, 
after  several  weeks  of  fever,  the  symptoms  gradually  disappearing 
and  the  patient  thinking  himself  well.  After  weeks  or  months,  a 
relapse  occurs,  to  be  followed  by  another  and  another,  any  of  which 
may  prove  fatal  or  lead  to  malarial  cachexia.  Spontaneous  recov- 
ery is  uncommon. 


MALARIA  583 

Pernicious  Malarial  Fever.  (Congestive  fever;  malignant  in- 
termittent fever;  malignant  remittent  fever;  congestive  chills.) 
This  form  is  due  to  the  estivo-autumnal  parasite  and  is  compara- 
tively rare.  Predisposing  causes  are  lesions  producing  a  general 
lowered  resistance  and  splenic  area  lesions,  exposure  to  hardships, 
intemperance,  previous  attacks  of  malaria,  or  other  exhausting  dis- 
eases. The  attacks  are  of  sudden  onset,  of  great  severity,  and  of 
many  forms.  Hyperpyrexia  has  temperature  of  107°  to  110°  F. 
or  higher. 

The  cerebral  type  is  due  to  plugging  of  the  cerebral  centers  by 
the  plasmodial  emboli.  Comatose,  convulsive,  and  paralytic  forms 
are  described. 

In  the  algid  form  no  febrile  reaction  occurs  after  the  chill ;  the 
body  surface  is  intensely  cold ;  the  rectal  temperature  is  104°  to 
107°  F.,  a  cold  sweat  covers  the  body;  the  radial  pulse  is  slow  and 
feeble  and  often  absent;  thirst  is  intense;  mind  clear,  the  counte- 
nance death-like,  and  case  ends  in  collapse. 

The  algid  type  is  due  to  an.  accumulation  of  the  parasites  in  the 
splanchnic  vessels,  with  mild  thrombosis  in  the  vessels  of  the  intes- 
tinal mucosa.  Recovery  from  one  or  several  attacks  may  occur, 
but  any  attack  may  be  fatal. 

Choleraic  (Dysenteric,  gastro-intestinal  type)  is  characterized 
by  stools  containing  bile,  intense  nausea,  vomiting,  purging,  tenes- 
mus, burning  sensation  in  the  stomach,  frequent  weak  pulse,  intense 
thirst,  cold  feet  and  hands,  and  face  with  shrunken  features,  cramps 
and  marked  depression.  This  lasts  from  one  half  to  several  hours. 

Thoracic  types  are  characterized  by  marked  dyspnea,  oppressed 
cough  with  blood-streaked  sputum,  frequent  weak  pulse,  cold  sur- 
face, terror  stricken  features,  and  intense  pulmonary  congestion. 

Blackwater  Fever.  (Hemoglobinuric  fever;  malarial  hemo- 
globinuria.) Occurs  in  tropical  Africa,  rarely  in  certain  parts  of 
India,  and  is  endemic  in  the  southern  states.  The  predisposing 
causes  are  prolonged  residence  in  malarial  regions ;  repeated  attacks 
of  malaria  which  have  led  to  anemia  and  debility ;  and  "prolonged 
use  of  quinine." — R.  Koch.    One  attack  predisposes  to  another. 

It  is  an  acute  hemolysis.  The  malarial  parasites  are  absent  or 
scanty  in  the  blood  during  an  attack  or  in  the  internal  organs  after 
death.  Red  corpuscles  are  rarely  found  in  the  urine,  but  hemo- 
globinuria is  severe.  There  is  cloudy  swelling  of  the  hepatic  and 
renal  cells,  the  skin  and  conjunctivae  are  yellow  or  brown  from 
jaundice. 

It  may  commence  as  an  ordinary  malarial  attack.  In  a 
few  days  a  severe  rigor  occurs,  the  urine  becomes  very  dark 
or  black,  is  at  first  copious,  later  diminished  or  suppressed;  there 
is  yellow  discoloration  of  the  skin  and  sclerotics;  bilious  vomiting; 


584  PROTOZOAN  INFECTIONS 

sharp  pains  in  the  loins  and  epigastrim;  usually  bilious  diarrhea. 
The  condition  may  either  pass  off  in  a  few  hours  not  to  recur; 
there  may  be  recurrences,  or  there  may  be  no  remission  at  all. 
Marked  anemia  and  prostration  develop  and  death  is  frequent. 
In  the  malarial  region,  the  slightest  chill  or  over-strain  may 
provoke  a  recurrence. 

Malarial  Cachexia.  Repeated  or  prolonged  attacks  of  malarial 
fever  lead  to  severe  cachexia.  It  may  be  impossible  to  find  the 
organism  in  the  blood. 

The  peculiar  characteristic  features  are:  anemia,  often  intense; 
sallow,  earthy  skin ;  tendency  to  hemorrhages  as  epistaxis,  pur- 
pura and  retinal  hemorrhages;  irregular  attacks  of  fever  or  of 
subnormal  temperature;  enlargement  of  the  spleen  and  liver. 
Complications  in  the  order  of  frequency  are :  orchitis,  neuralgia, 
headache,  paraplegia,  enteritis,  nephritis,  rheumatism,  typhoid 
fever,  lobar  pneumonia,  jaundice  and  dysentery.  The  patients 
finally  succumb  to  general  weakness,  tuberculosis,  gangrene,  or 
amyloid  degeneration  of  the  internal  organs. 

Diagnosis.  Malaria  is  recognized  by  the  symptoms  peculiar  to 
the  types  as  given,  and  by  the  presence  of  the  parasites  in  the 
blood. 

Blood  in  malaria.  Red  cells  are  destroyed  so  the  count  is  de- 
creased after  each  paroxysm,  but  the  number  is  almost  restored 
before  the  next  attack.  The  anemia  is  progressive.  The  cells  con- 
tain granules  and  the  parasite  in  its  various  forms.  Some  forms  are 
free  in  the  plasma.  Melanin  is  the  pigment  free  in  the  blood 
stream  and  in  the  organs  in  which  the  plasmodia  collect.  Hemo- 
globinemia  may  occur.  In  the  estivo-autumnal  form,  the  new  cells 
are  pale,  varying  in  size  and  shape,  nucleated  reds  are  common, 
regeneration  is  slow.  There  is  extensive  necrosis  and  resulting 
induration  of  the  bone  marrow.  The  hemoglobin  suffers  more  than 
the  red  cells  and  returns  to  normal  much  more  slowly. 

Leucocyte  count  is  always  subnormal,  with  a  slight  rise  just 
before  a  paroxysm  and  then  steadily  decreasing  until  the  tempera- 
ture is  lowest,  sometimes  to  1000  to  2000  cells  per  cubic  millimeter. 
The  differential  count  shows  a  relative  decrease  in  the  polymorpho- 
nuclears, an  absolute  increase  in  the  large  mononuclears,  especially 
pronounced  in  the  apyretic  periods  and  usually  absent  in  the  fever 
period. 

The  diagnosis  is  made  positive  by  finding  the  plasmodium 
malariae  in  the  blood.  Children  may  only  show  the  enlarged  spleen 
clinically. 

Malaria  must  be  distinguished  from  tuberculosis,  pyemia  or 
concealed  suppuration,  pyelitis,  ulcerative  endocarditis,  and  gall- 
stones; the  remittent  type  from  typhoid  fever;  and  the  pernicious 
form  from  yellow  fever. 


MALARIA  585 

Treatment.  The  most  common  lesions  are  found  as  lateral 
deviations  between  the  seventh  and  twelfth  dorsal  and  the  fourth 
lumbar  vertebrae  with  consequent  displacement  of  the  ribs  in  con- 
nection with  the  dorsal  lesions.  During  the  chill  give  vigorous 
treatment  to  the  whole  spinal  column.  Deep  steady  pressure  at  the 
eighth  dorsal  also  assists  in  stopping  the  chill,  or  in  lessening  the 
next  one.  Raise  the  ribs  over  spleen  and  liver.  Deep  steady 
pressure  to  the  suboccipital  nerves  reduces  the  temperature. 
Sponging  is  grateful  to  the  patient.  "I  adjust  all  the  bones  of  the 
neck  because  I  wish  to  relieve  the  congestion  of  the  cerebellum, 
medulla,  and  all  the  nerves  above  the  diaphragm." — A.  T.  Still. 

Muscular  contractions  with  marked  hypersensitiveness  appear 
in  the  interscapular  region  just  before  the  onset  of  the  chill.  Vig- 
orous treatment  relieving  this  tension,  with  correction  of  lesions 
and  increase  of  spinal  flexibility  may  prevent  the  entire  paroxysm, 
or  greatly  diminish  its  severity. 

During  the  sweating  stage,  deep  steady  pressure  in  the  sub- 
occipital fossa,  treatment  at  the  upper  dorsal  and  first  lumbar  are 
all  necessary.  If  no  further  symptoms  are  noted,  the  patient  must 
be  treated  upon  the  third,  fifth,  seventh,  fourteenth  and  twenty-first 
days  as  a  prophylactic  measure. 

In  blackwater  fever,  fluids  should  be  given  especially  freely  to 
flush  the  tubules  and  avert  suppression.  Special  attention  must  be 
given  to  the  renal  splanchnic  area  and  gentle  direct  treatment  to 
the  abdomen.  In  very  serious  cases,  normal  saline  should  be  given 
subcutaneously  or  by  rectum  to  make  up  the  amount  of  fluid  and 
avert  collapse.  On  no  account  should  the  patient  sit  up  owing  to 
the  risk  of  cardiac  failure. 

"When  the  patient  has  the  quartan  parasite,  as  soon  as  the  temperature 
begins  to  fall  I  give  him  from  two  to  six  ounces  of  red  meat  juice,  extracted 
from  rare  beefsteak,  sometimes  as  much  as  five  pounds  in  the  first  twenty-four 
hours  following  the  chill.  In  almost  all  cases  of  quartan  malaria  the  blood  is 
built  up  sufficiently  by  the  time  they  reach  the  second  cycle  to  pass  without  the 
patoxysm,  or  chill.  By  the  time  for  the  third  cycle,  whicTi  is  the  seventh  day, 
I  always  have  built  up  the  patient's  resistance  so  as  to  enable  him  to  pass  by 
this  cycle  without  any  symptoms  of  malaria  whatever.  In  cases  of  double  or 
triple  I  find  the  same  treatment  causes  about  the  same  results.  I  do  not  give 
any  other  diet,  except  dry  toast  if  they  eat  the  beef  instead  of  taking  the  juice. 
If  they  can  take  the  steak  I  prefer  their  taking  it,  but  almost  all  cases  prefer 
the  juice.  *  *  *  The  treatment  for  the  tertian  type  of  malaria  is  practically 
the  same  as  the  treatment  for  the  quartan. 

"The  estivo-autumnal  type  of  malaria  diflfers  from  the  quartan  and  tertian 
types ;  first,  in  that  the  paroxysms  are.  as  a  rule,  much  more  irregular ;  second, 
they  are  much  longer  in  duration;  third,  the  chills  are  more  frequently  absent; 
fourth,  the  fever  is  often  irregular,  intermittent,  remittent,  or  continuous  in 
character.  This  type  very  often  takes  the  form  of  blackwater  or  hemoglobin- 
uric  type  with  hemorrhagic  symptoms,  with  hemorrhage  from  nose,  gums  and 
bowels.  The  first  thing  to  do  in  a  case  of  hemorrhagic  malaria  is  to  put  an 
ice  bag  on  the  abdomen,  which  will  tend  to  control  the  hemorrhage  from  the 
kidneys.  Give  the  palient  all  the  red  beef  juice  you  can  get  him  to  take,  provided 
he  has  not  developed  a  very  sick  stomach;  if  so,  give  him  high  saline  enemas 


586  PROTOZOAN  INFECTIONS 

and  in  one  half  hour  give  him  four  ounces  red  beef  juice  per  rectum.  Repeat 
the  feeding  per  rectum  in  four  hours.  As  soon  as  he  can  retain  anji:hing  on 
stomach  give  him  all  the  juice  he  can  take  comfortably.  Treat  the  liver  thor- 
oughly— at  least  three  times  in  the  first  twenty-four  hours.  At  the  end  of 
thirty-six  hours  the  yellow  cast  will  be  very  much  lighter,  which  is  a  sure 
sign  that  the  patient  is  getting  better.  Watch  the  urine  closely.  The  third  day 
there  may  occur  a  suppression.  If  so,  give  strong  stimulation  to  the  renal  plexus 
through  the  abdomen,  and  be  sure  there  is  a  thorough  relaxation  of  the  dorsal 
and  lumbar  muscles. 

"It  is  an  established  fact  that  people  in  the  malarial  districts  eat  very  little 
beef.  I  find  thai  ninety-nine  per  cent  of  the  cases  of  malaria  never  eat  it,  or 
when  they  on  rare  occasion  do,  it  has  been  so  overcooked  that  all  the  blood- 
building  substances  have  been  destroyed.  The  beef  raw  would  be  better  in  my 
opinion ;  although,  the  possible  chance  of  getting  a  tapeworm  or  animal  parasite 
is  so  considerable  that  I  would  advise  that  the  beef  should  be  heated  to  250 
degrees  F." — E.  C.  Armstrong. 

Prognosis.  In  the  intermittent  type  the  outlook  is  always  favor- 
able with  treatment.  The  remittent  type  usually  ends  in  recov- 
ery with  treatment,  but  death  may  occur  in  very  severe  cases. 

Prophylaxis  is  important.  Properly  screened  windows  and  doors 
of  all  buildings  are  necessary,  especially  where  malarial  patients  are 
ill.  Wage  a  crusade  against  the  larvae  of  the  Anopheles,  by  drain- 
age of  marshes  and  stagnant  pools,  by  covering  those  recently 
drained  and  those  undrained  with  a  film  of  kerosene  or  crude  pe- 
troleum. In  tropical  towns,  those  not  native  should  live  in  a  sep- 
arate quarter  and  avoid  being  out  at  night.  Isolation  of  the 
patient  from  mosquitoes  prevents  spread  of  infection  and  also  rein- 
fection of  himself. 


TROPICAL  SPLENOMEGALY 

(Kala-azar;  dum-dum  fever;  tropical  cachexia;  piroplasmosis) 

This  is  a  tropical  disease  occurring  chiefly  in  India,  Ceylon, 
China,  and  Egypt,  caused  by  the  parasite  Leishmania  Donovani, 
which  is  conveyed  by  bedbugs  and  perhaps  fleas,  and  is  found  in 
the  spleen,  liver,  and  bone  marrow.  It  is  a  disease  of  rats  and  dogs 
also,  and  these  perpetuate  and  transmit  it.  It  is  characterized 
clinically  by  great  enlargement  of  the  spleen  and  liver,  anemia  and 
leucopenia,  hemorrhages  from  mucous  surfaces  and  purpura ;  irreg- 
ular fever,  transitory  edema,  later  muscular  atrophy  and  great 
emaciation  and  cutaneous  ulcers.  An  infantile  form  occurs  in  Italy 
and  Greece. 

Diagnosis  is  by  hepatic  puncture  to  find  the  parasite  in  the 
fluid. 

Treatment.  The  prevention  is  of  utmo.=t  importance.  Cleanli- 
ness and  the  destruction  of  bedbugs  and  rats,  isolation  of  the  sick 
and  their  protection  from  bedbugs,  are  prophylactic.  After  the 
disease  appears,  treatment  must  be  symptomatic  and  supporting. 


ROCKY  MOUNTAIN  FEVER  .  587 

Prognosis.  Recovery  is  not  to  be  expected.  The  disease  may- 
last  for  months  or  years,  or  be  fatal  within  a  few  weeks. 

CUTANEOUS  LEISHMANIASIS 

(Oriental  sore;  Biscra  button;  tropical  ulcer;  Aleppo,  Delhi,  or  Bagdad  boil; 

natal  sore) 

This  is  very  common  in  Oriental  countries ;  it  seems  to  be  lim- 
ited to  the  countries  in  which  the  camel  is  used.  The  infection 
appears  to  be  identical  with  that  of  kala  azar,  but  it  is  less  virulent. 
The  possibility  that  it  is  the  same  organism,  modified  by  its  trans- 
mission through  the  camel,  is  of  interest.  The  sores  appear  only 
upon  exposed  portions  of  the  body,  beginning  as  small  red 
macules,  which  slowly  increase  in  size  and  discharge  pus.  A 
crust  forms,  drops  off,  and  exposes  a  granulating  ulcer.  The  crusts 
keep  forming  and  dropping  off,  leaving  ulcers  of  increasing  size, 
which  after  months  or  years  heal,  leaving  a  depressed  scar  and  often 
great  deformity. 

One  attack  confers  immunity.  The  diagnosis  is  made  by  the 
characteristic  sore,  and  by  finding  the  Leishman-Donovan  bodies 
in  the  granulation  tissue.  The  treatment  consists  in  the  surgical 
dressing  of  the  sores,  and  such  constitutional  treatment  as  may  be 
indicated  on  examination. 

Prophylaxis.  Any  contact  with  persons  suffering  with  sores 
upon  them,  in  the  tropics,  or  among  people  recently  arrived  from 
the  tropics,  should  be  surrounded  with  precautions.  The  hands 
must  be  well  gloved,  and  thoroughly  washed  often.  Travelers  in 
tropical  countries  are  to  be  careful,  since  they  possess  little  or  no 
immunity  to  many  of  these  diseases.  The  bites  of  insects  are 
especially  to  be  avoided. 

ROCKY  MOUNTAIN  FEVER 

(Rocky  Mountain  spotted  fever;  tick  fever) 

Rocky  Mountain  fever  is  an  acute  infection  caused  by  piro- 
plasma  hominis,  and  transmitted  by  the  tick,  Dermacentor  reticu- 
latus,  and  characterized  by  chill,  fever,  pains  in  the  back  and  bones, 
and  a  characteristic  eruption.  • 

The  disease  is  limited  to  the  Rocky  Mountains  between  40°  and 
47°  N.,  and  is  most  prevalent  at  3,000  to  4,000  feet  elevation.  _ 

The  disease  confers  immunity  and  this  in  animals  is  transmitted 
to  their  young.    Incubation  is  from  three  to  ten  days. 

Diagnosis.  The  disease  begins  with  a  chill,  fever,  103°  to  105° 
F.,  severe  pains  in  the  back  and  limbs,  a  rash  appearing  from  the 
second  to  the  seventh  day  which  is  macular,  dark  and  becomes 
hemorrhagic.     The  skin  is  often  swollen.     At  the  height  of  the 


588  PROTOZOAN  INFECTIONS 

fever,  there  may  be  delirium  and  stupor.    Convalescence  begins  in 
the  fourth  week. 

The  history  of  exposure  to  the  danger  of  tick-bite,  with  the 
symptoms,  gives  the  diagnosis.  The  red  blood  cells  show  destruc- 
tion ;  the  hemoglobin  diminishes  rapidly,  sometimes  to  fifty  per 
cent. 

Treatment.  The  symtoms  must  be  treated  as  they  arise.  Warm 
continuous  baths  may  control  the  pain  and  the  delirium.  Treat- 
ment to  control  the  circulation,  especially  through  the  liver  and 
spleen,  is  indicated.  During  convalescence  the  treatment  for  the 
secondary  anemia,  raising  the  ribs,  is  important  and  the  diet 
should  be  rich  in  chlorophyll  and  nitrogenous  foods. 

Prognosis.  Different  localities  give  very  different  fatalities,  to- 
tally apart  from  therapeutic  considerations. 

Prophylaxis.  The  destftiction  of  the  tick  is  difficult.  The  piro- 
plasm  is  transmitted  to  the  young  ticks,  and  these  transmit  the 
disease.  Persons  who  are  much  in  the  woods  should  protect  them- 
selves from  danger  of  tick-bite,  by  thick  clothing  and  shoes.  As 
rapidly  as  possible,  the  tick  should  be  completely  exterminated. 

FLAGELLATA 

(Mastigophera) 

These  are  unicellular  organisms,  microscopic  in  size.  They  are 
nucleated,  and  may  be  green,  with  chlorophyll  bodies. 

Trichomonas  vaginalis  is  found  in  the  vagina  of  both  pregnant 
and  non-pregnant  women,  especially  if  the  secretions  are  acid,  but 
may  not  cause  any  particular  disturbance.  Chronic  vaginitis  with 
pruritis  was  found  associated  with  this  organism  in  two  P.  C.  O. 
Clinic  cases. 

Trichomonas  intestinalis  is  associated  with  chronic  diarrhea, 
especially  in  the  tropics. 

Trichomonas  pulmonale  have  been  found  in  the  sputum  in  cases 
of  gangrene  of  the  lung  and  in  pleural  exudates. 

Lamblia  intestinalis  inhabits  the  jejunum  and  duodenum  caus- 
ing a  chronic  diarrhea. 


TRYPANOSOMIASIS 

(Sleeping-sickness)     . 

Trypanosomiasis  is  a  chronic  disease  of  tropical  Africa  and 
other  countries,  clinically  marked  by  fever,  wasting,  lassitude,  en- 
largement of  the  glands  and  a  terminal  stage  of  lethargy.  The 
exciting  cause  is  the  protozoon,  trypanosoma  gambiense,  which  is 
conveyed  by  the  tsetse  fly.    Natives  of  West  African  coast,  Congo 


AMEBIC  DYSBNTBRY  589 

basin,  Uganda,  and  the  course  of  the  Niger  ar.e  chiefly  attacked, 
but  Europeans  are  not  exempt.    The  incubation  time  is  unknown. 

Diagnosis.  The  organism  may  be  in  the  blood  for  years  without 
symptoms.  This  form  is  marked  by  recurrent  attacks  of  fever  re- 
sembling malaria,  with  glandular  enlargement,  with  intervals  of 
apparent  health. 

In  other  cases  there  is  lassitude  from  the  first,  with  slow  gait 
and  speech,  headache,  and  nocturnal  fever.  The  glands  are  usually 
enlarged.  Irregular  edema  and  dropsy,  anemia,  firie  tremors  of 
the  tongue  and  hands,  and  wasting  lead  into  the  terminal  stage. 
There  is  gradually  deepening  coma  (sleeping  sickness),  which  may 
be  accompanied  by  convulsions,  paralysis,  or  bed  sores.  The  dura- 
tion of  the  disease  varies  from  a  few  months  to  years,  and  death 
often  occurs  from  an  intercurrent  affection. 

Several  species  of  trypanosomes  have  been  described.  In  Brazil 
children  are  affected  by  the  Schizotrypanum  cruzi.  It  invades  the 
thyroid,  causing  symptoms  of  acute  myxedema.  High  fever,  en- 
larged lymph  glands,  spleen  and  liver,  meningitis  or  encephalitis, 
lead  either  to  death  or  to  permanent  nervous  lesions.  Carriers  of 
the  disease  may  suffer  slightly  or  not  at  all. 

The  protozoon  is  more  readily  found  in  the  glandular  tissue 
than  in  the  blood. 

Prophylaxis.  The  method  of  combatting  the  disease  is  war 
against  the  tsetse  fly  and  protection  from  it. 

PSOROSPERMIASIS 

This  disease  in  man  is  due  to  infection  by  coccidia  oviforme, 
which  is  the  cause  of  spotted  liver  of  rabbits.  It  is  rare  in  man, 
and  is  clinically  characterized  by  intermittent  fever,  diarrhea, 
nausea,  tenderness  over  the  liver  and  spleen,  and  drowsiness,  and 
pathologically  by  caseous  foci  with  rings  of  congestion  in  the  liver, 
spleen,  and  intestines  resembling  tubercles,  but  containing  the 
coccidia.    Death  is  inevitable  when  the  disease  is  recognized. 

Cutaneous  psorospermiasis  (keratosis  follicularis)  may  greatly 
resemble,  perhaps  even  may  cause,  neoplasms  of  the  skin. 

Treatment.  Surgical  removal  of  the  skin  lesions  is  indicated  in 
favorable  cases. 

Prophylaxis  consists  in  cleanliness.  Especially  when  rabbits 
are  allowed  to  run  about  in  a  vegetable  garden,  there  is  danger  in 
eating  raw  vegetables  or  small  fruits. 

AMEBIC  DYSENTERY 

Amebic  dysentery  is  an  acute  or  chronic  inflammation  of  the 
mucous  membrane  of  the  large  intestine,  caused  by  the  ameba 


590  PROTOZOAN  INFECTIONS 

dysenteriae  and  characterized  by  fever,  tormina,  weakness,  frequent 
watery  stools  containing  gelatinous  mucous  masses,  with  a  special 
liability  to  hepatic  abscess. 

Etiology.  The  exciting  cause  is  either  the  entameba  tetragena. 
or  the  entameba  histolytica.  It  is  swallowed  in  contaminated 
water  and  upon  uncooked  vegetables. 

Predisposing  causes  are  lesions  of  the  lumbar  region,  especially 
the  third,  fourth  and  fifth,  which  are  usually  far  back  on  the  sacrum, 
this  posterior  condition  extending  as  far  up  as  the  tenth  dorsal. 
Contractions  occur  all  along  the  spinal  musculature. 

Diagnosis.  The  onset  is  gradual  (a  frequent  and  painless  diar- 
rhea following  a  period  of  ill-health)  or  abrupt,  marked  by  the 
passage  of  many  small,  watery  stools  containing  mucus  but  no 
blood,  and  alternating  with  constipation.  The  milder  cases  are  at- 
tended by  weakness  and  emaciation,  and  dull  expression ;  pale  and 
sallow  skin,  pale,  flabby,  moist,  and  slightly  furred  tongue,  and  in- 
somnia. The  temperature  does  not  rise  above  100  F.,  the  pulse 
feeble,  ranging  from  70  to  90.  The  abdominal  pain  is  constant, 
cramp-like,  dull  aching  or  burning,  mainly  in  the  upper  quadrants. 

Tenesmus  is  infrequent,  but  there  is  a  burning  sensation  in  the 
rectum  and  in  the  anus  during  and  after  passage  of  feces.  The 
tendency  to  chronicity  is  great.  In  the  grave  form,  the  face  is 
drawn,  cyanosed  or  flushed,  the  expression  anxious,  the  mind  clear; 
there  is  anorexia,  intense  thirst,  and  sleeplessness  with  normal  or 
subnormal  temperature,  small,  rapid  pulse,  and  free  sweating.  Re- 
tracted abdomen  and  greenish-yellow  color  of  the  skin  with  pro- 
gressive anemia  and  emaciation  may  dominate  the  intestinal 
symptoms.  Death  may  occur  in  a  few  days  or  at  any  time  for 
months  from  hemorrhage,  perforation,  sloughing,  hepatic  abscess, 
or  exhaustion. 

The  chronic  form  may  follow  the  acute  attack,  or  it  may  be 
chronic  from  the  first.  The  symptoms  resemble  the  bacillary  dysen- 
tery but  there  is  more  definite  tendency  to  alternating  periods  of 
diarrhea  and  constipation.  The  tongue  is  red,  glazed  and  beefy. 
The  appetite  is  capricious,  the  digestion  is  easily  disordered.  In 
the  United  States  the  patients  retain  their  nutrition  remarkably  well 
in  contrast  to  the  marked  emaciation  of  those  in  the  tropics.  Diar- 
rhea may  be  the  only  symptom  and  characterized  by  great  variation 
in  character  and  frequency.  Exacerbations  may  begin  suddenly 
and  subside  in  the  same  manner,  lasting  from  two  to  ten  days.  The 
intermissions  continue  from  one  day  to  three  weeks,  during  which 
feces  are  soft  but  contain  mucus.  This  periodicity  is  most  marked 
in  cases  with  hepatic  abscess.    True  relapses  are  common. 

The  complications  include  hepatic  abscess  and  other  abscesses 
with  rupture  usually  into  the  lung.  This  is  indicated  by  dry,  hack- 
ing cough,  sudden  expectoration  of  diffluent,  tenacious,  alkaline, 


AMEBIC  DYSBNTBRY  591 

frothy  sputum  with  odor  like  "anchovy-sauce."  This  contains  the 
amebse  with  blood,  bile  constituents,  and  sometimes  degenerated 
liver  cells.  Conjunctivitis  or  vaginitis  may  be  due  to  direct  infection 
by  soiled  fingers. 

Diagnosis  depends  upon  finding  the  ameba  in  the  stools  or  pus 
by  the  microscopic  examination  preferably  on  a  warm  stage. 

In  the  chronic  form  the  urine  is  often  albuminous  and  may  con- 
tain casts.  In  the  gangrenous  form,  there  may  be  retention. 
Amebae  are  not  present  unless  the  bladder  becomes  infected.  There 
is  varying  anemia.  Mild  leucocytosis  is  the  rule ;  sometimes 
eosinophilia  is  present.  At  first  the  stools  are  small,  consisting  of 
mucus,  with  more  or  less  bright  blood  and  small  fecal  masses,  four 
to  twenty  or  more  each  day.  As  ulceration  advances,  they  become 
more  copious  and  watery,  feces  and  blood  diminished,  and  con- 
taining gelatinous  grayish  masses  about  one  to  three  centimeters 
in  diameter.  When  sloughing  occurs,  shreddy  masses  of  necrotic 
tissue  are  found. 

Treatment.  The  first  work  in  treatment  is  to  adjust  the  lumbar 
vertebrae,  especially  the  second  and  third.  Other  lesions  are  cor- 
rected as  found. 

There  is  nothing  yet  known  which  kills  the  amebae  with  no 
harm  to  the  patient.  The  only  thing  is  to  keep  the  intestinal  tract 
clean,  and  to  get  rid  of  the  amebae  with  the  feces.  The  fact  of  the 
frequent  stools  does  not  prove  that  retention  is  not  occurring.  Fre- 
quent washing  of  the  colon  helps  to  clear  away  retained  masses, 
if  these  can  be  felt  on  palpation,  or  if  the  dysentery  is  not  relieved, 
by  the  ordinary  measures.  The  "drop  method"  may  be  employed  if 
the  usual  enemas  are  irritating  or  unsuccessful. 

Diet.  In  chronic  cases,  cellulose  may  be  freely  employed,  if  it 
does  not  precipitate  a  more  acute  attack.  Probably  there  is  nothing 
which  is  more  completely  and  thoroughly  cleansing  to  the  entire 
intestinal  tract  than  a  full  cellulose  diet,  with  plenty  of  water 
drinking.  Pineapple,  apples,  celery,  lettuce,  onions,  raw  cabbage, 
carrots,  all  should  be  eaten  in  abundance,  and  the  amounts  of 
proteid,  carbohydrate  and  fatty  foods  kept  to  a  rather  low  measure 
of  the  metabolic  requirements  of  the  body.  The  food  must  be 
liquid  during  an  acute  attack. 

For  the  conjunctivitis  or  vaginitis,  which  may  result  from  acci- 
dental contamination,  frequent  washing  with  any  bland  and  non- 
irritating  liquid  is  the  best  thing.  The  inflammation  which  may 
icsult  from  the  infection  is  best  treated  by  the  usual  osteopathic 
methods  of  treating  simple  inflammation  of  those  membranes. 
Hepatic  abscess,  or  the  rare  abscesses  in  other  parts  of  the  body, 
reaujre  surgical  evacuation. 

Prognosis.  The  majority  of  cases  recover  from  the  acute  at- 
tacks.   The  chronic  form  may  persist  for  years. 


592  PROTOZOAN  INFECTIONS 

Prophylaxis.  Especially  since  more  frequent  communication 
with  tropical  countries  it  is  necessary  to  be  sure  of  the  purity  and 
cleanliness  of  water  and  food  supply.  Cases  in  southern  California 
have  been  caused  by  the  ameba  upon  salad  vegetables  irrigated 
with  contaminated  water.    Disinfect  all  stools  and  urine  of  patients. 

MYIASIA 

The  larvae  of  flies  and  other  dipterous  insects  occasionally  gain 
entrance  into  the  human  body,  either  with  food  or  by  direct  in- 
vasion of  the  orifices  or  ulcers  upon  the  skin.  The  screw-worm 
compsomyia  macellaria  is  the  most  common  in  the  United  States. 
The  larvae  of  dermatobia  noxialis,  lucilia  serricata  and  lucilia 
caesar  are  occasionally  found  responsible  for  myiasia. 

The  destructive  powers  of  these  larvae  are  surprising.  They 
may  invade  the  brain  by  way  of  the  nasal  passages  and  cribriform 
plate  or  the  eye-ball  from  the  conjunctiva,  or  the  muscles,  cartil- 
ages and  bones  from  skin  lesions. 

The  only  efficient  treatment  is  surgical  removal  of  the  infested 
tissues.  If  this  is  impossible  recovery  may  occur  as  the  result  of 
the  death  of  the  parasite,  but  in  most  cases  death  of  the  patient 
is  speedy  and  inevitable. 


CHAPTER  LII 
NEMATODES 

Nematode  (threadlike)  worms  are  round  and  usually  very  small. 
They  include  a  number  which  produce  diseases  of  varying  severity, 
in  the  human  race  as  well  as  among  animals.  They  include  the 
following  worms : 

Strongyloides  intestinalis.  (Rhabdonema  strongyloides ;  Anguil- 
lula  intistinalis  et  stercoralis.) 

Filaria  sanguinis  hominis.     (F.  Bancrofti.) 

Dranunculus  or  filaria  medinensis.  (Guinea  worm;  Medina 
worm.) 

Trichocephalus  dispar.  (Trichinis  trichinora;  Common  whip- 
worm.) 

Trichina  spiralis.     (Flesh-worm;  Pseudalius  trichina.) 

Ankylostoma  duodenale. 

Necator  or  Uncinaria  americana. 

Ascaris  lumbricoides. 

Oxyuris  vermicularis.     (Ascaris  vermicularis.) 

Ascaris  alata.     (Mystax.) 

Nematodes  rarely  found  as  causes  of  disease  in  man  in  this 
country  include  the  following: 

Strongyloides  intestinalis  (Anguillula  stercoralis)  occurs  chiefly 
in  Asia,  and  is  not  known  to  be  pathogenic  to  its  human  host. 

Eustrongylus  gigas  is  a  very  large  round  worm,  about  a  meter 
long,  which  is  very  common  in  dogs  and  other  carnivora,  but  is  a 
rare  parasite  of  man.  It  attacks  the  kidney,  causing  hematuria. 
The  ova  may  be  found  in  the  urine. 

Trichocephalus  dispar  or  common  whip-worm  is  co'mmon  in 
Syria  and  Egypt,  being  an  inhabitant  chiefly  of  the  cecum,  ap- 
pendix, and  the  large  intestine,  and  rarely  causing  symptoms.     It 
is  al^ut  an  inch  long,  the  anterior  half  being  thin  and  thread-like, 
,^ — and  the  posterior  part  much  thicker. 

^^^-^       Ascaris  mystax  (Alata)  is  two  to  three  inches  long,  infests  cats 
^and  dogs,  rarely  man. 

Filaria  sanguinis  hominis  infects  the  blood. 

DRACONTIASIS 

(Guinea  worm  disease;  dranunculosis ;  medina  worm  disease) 
This  disease  is  due  to  infection  by  the  persarum,  or  dranunculus 
mediensis.     The   worm   passes   one  part   of  its   existence   in   the 
Cyclops,  a  crustacean.  The  disease  is  characterized  clinically  (about 

593 


594  NBMATODB  WORMS 

a  year  after  the  ingestion  of  the  polluted  water)  by  the  appearance 
of  a  small  blister  usually  just  above  the  ankle,  the  event  ushered 
in  with  fever,  sometimes  urticarial  rashes.  The  blister  ruptures 
and  through  the  small  ulcer  is  seen  the  female  worm's  head  with 
the  coils  felt  like  a  bundle  of  cords  beneath  the  skin.  By  playing 
a  stream  of  water  over  the  ulcer,  the  embryos  are  discharged  and 
the  worm  leaves  her  host. 

The  patient  is  unable  to  walk  but  there  are  no  other  symptoms 
than  the  local  irritation  unless  pyogenic  infection  occurs.  There 
may  be  more  than  one  extruding  at  a  time.  The  male  worm  has 
not  been  found. 

Treatment.    The  native  treatment  is  unique  but  effective. 

As  the  worm  begins  to  leave  she  is  wrapped  about  a  small  piece 
of  smooth  wood  to  prevent  retraction,  and  day  by  day  the  patient 
winds  a  little  more  of  the  worm  on  the  wood,  being  careful  not  to 
tear  her,  doing  this  until  she  is  finally  extracted. 

Prophylaxis.  In  order  to  avoid  this  infection,  it  is  necessary  to 
avoid  drinking  water,  or  bathing  in  water,  which  might  be  the  home 
of  Cyclops  in  tropical  countries. 

OXYURIS  VERMICULARIS  OR  THREAD-WORMS 

The  male  is  one-eighth  inch  long  with  a  curved  tail ;  the  female 
is  about  one-fourth  inch,  thin  and  thread-like  with  a  tapering  tail. 
They  gain  entrance  to  the  body  by  water  or  upon  salad  vegetables, 
and  inhabit  the  large  intestine,  especially  the  rectum  and  descend- 
ing colon,  and  are  often  found  around  the  anus. 

Diagnosis.  The  patient  is  usually  a  child  who  is  extremely  rest- 
less  and  irritable ;  the  sleep  is  disturbed ;  there  is  loss  of  appetite ; 
there  may  be  anemia  of  a  more  or  less  marked  degree ;  vesical  and 
rectal  tenesmus  and  priapism  may  be  present.  Itching  and 
erythema  around  the  anus  and  perineum  is  very  annoying,  and  if 
the  worms  reach  the  penis  in  boys,  or  the  vagina  in  girls,  may  cause 
masturbation.  This  symptom  is  worse  when  worms  come>iQ^n 
and  especially  at  night  when  warm  in  bed. 

The  pruritis  leads  to  scratching,  and  thus  the  ova  may  becom 
lodged  around  the  finger  nails.  No  unusual  carelessness  then  i 
necessary  to  permit  infection  of  the  food,  and  thus  the  infection  of 
others,  or  a  second  infection  of  the  patient.  The  feces  contain  the 
ova  in  large  numbers. 

Treatment.  Merely  the  repeated  washing  of  the  rectum  with 
warm  soapy  water,  or  an  emulsion  of  oil  and  soap,  will  usually 
clean  the  body  of  the  worms.  For  more  speedy  relief,  quassia  decoc- 
tion— about  an  ounce  to  a  pint  of  water — may  be  injected  into  the 
rectum  and  left  for  a  short  time.    This  procedure  may  be  repeated 


FILARIASIS  595 

once  a  wee"k  or  so,  until  no  further  evidence  of  the  worms  can  be 
found. 

Usually  spinal  rigidity  and  lesions  involving  the  lumbar  ver- 
tebrae are  found ;  the  correction  of  these  conditions  promotes  recov- 
ery from  the  malnutrition  and  nervous  irritability  due  to  the  pres- 
ence of  the  worms. 

Prophylaxis.  The  carelessness  associated  with  defecation, 
especially  in  children  and  in  uncleanly  adults,  permits  the  spread 
of  these  organisms.  The  use  of  raw  vegetables  irrigated  with  sew- 
age or  grown  in  fields  enriched  with  excrement  is  dangerous. 

ASCARIS  LUMBRICOIDES 

(Common  round  worm) 

The  male  is  four  to  six  inches  long ;  the  female  is  ten  to  sixteen 
inches,  they  resemble  the  ordinary  earth-worm  in  appearance. 
They  inhabit  the  small  intestine  but  exhibit  a  marked  tendency  to 
wander  to  other  parts. 

Diagnosis.  In  children,  who  are  usually  affected,  they  produce 
many  reflex  symptoms  as  restlessness,  irritability,  twitchings,  pick- 
ing at  the  nose,  grinding  the  teeth,  foul  breath,  and  often  convul- 
sions. Gastro-intestinal  catarrh  without  any  other  cause  is  often 
present.  Eosinophilia  is  present,  and  in  some  cases  there  is  a 
marked  anemia. 

The  stools  show  the  adult  worm,  the  ova,  and  sometimes  both. 

Treatment.  Thorough  treatment  to  the  liver,  correction  of  all 
spinal  defects,  and  careful  direct  abdominal  treatment  is  essential 
to  provide  a  good  blood  stream  freely  circulating  and  good  digestive 
juices  which  will  make  the  intestines  a  poor  place  for  the  parasites. 

Cleanliness  must  be  insisted  upon ;  correction  of  the  whole 
hygiene  and  the  diet  is  necessary  for  a  complete  recovery. 

It  is  sometimes  necessary  to  kill  the  parasites  quickly.  For 
this  five  drops  of  oil  of  wormwood,  on  a  lump  of  sugar,  taken  after 
a  fast  of  at  least  twenty-four  hours,  is  usually  efficient.  Santonin 
is  used,  but  sometimes  produces  symptoms  of  poisoning.  No  drug 
taken  to  kill  the  worms  is  apt  to  be  effective  unless  the  intestinal 
tract  has  first  been  pretty  thoroughly  emptied  of  its  contents.  Con- 
stant and  thorough  cleanliness  is  the  important  thing  to  prevent 
recurrence. 

FILARIASIS 

This  is  a  disease  of  the  tropics  due  to  the  presence  of  one 
of  several  filaria  in  the  blood.  These  include  filaria  sanguinis 
hominis,  both  nocturna  and  diurna,  and  the  less  common  filaria 
perstans,  filaria  demarquai  and  filaria  Philiipinensis.     The  adult 


596  NEMATODE  WORMS 

forms,  which  live  only  in  the  lymphatic  nodes,  were  called  filaria 
Bancrofti  and  filaria  loa.  The  latter  is  the  cause  of  the  Calabar 
swellings ;  its  embryonic  form  is  called  filaria  s.  h.  diurna. 

Filaria  s.  h.  nocturnis  is  the  most  common  form ;  the  embryos 
appear  in  the  blood  only  at  night.  The  embryos,  sometimes  the 
adult  worms,  may  block  the  lymphatic  vessels,  even  the  thoracic 
duct.    The  mosquito,  Culex  fatigans,  is  the  intermediate  host. 

The  filarial  embryos,  after  entering  the  mosquito's  bod}^  cast 
their  sheaths  and.bore  through  the  intestine  of  the  insect,  enter  the 
body  cavity,  find  their  way  to  the  head  and  there  enter  the  pro- 
boscis. Hence  they  leave  the  insect  when  it  bites  a  warm  blooded 
animal  or  man.  The  filaria  may  live  for  years  in  the  human  body 
without  causing  symptoms.  In  other  cases,  they  cause  pain  in  the 
back,  abdomen,  or  perineum,  chiefly  from  lymphatic  obstruction, 
and  lead  to  various  enlargements. 

The  filaria  are  found  also  in  the  glands,  membranes  of  the  testes, 
pelvis  of  the  kidney,  ureter,  and  bladder,  and  in  the  vitreous  humor. 

The  disturbances  produced  by  this  nematode  are  as  follows: 
chyluria  (milky  urine),  sometimes  slightly  tinged  with  blood,  is 
due  to  the  rupture  of  obstructed  lymphatic  vessels  into  the  urinary 
tract.  The  condition  is  usually  intermittent.  The  patient  may  be 
inconvenienced  only  by  the  passage  of  the  blood  clots  from  the 
bladder  and  the  uneasy  sensation  in  the  lumbar  region.  The  urine 
is  albuminous,  contains  fat  granules  and  filarise,  and  coagulates  upon 
standing. 

Lymph-scrotum  is  the  condition  found  when  the  scrotal  tissues 
are  greatly  thickened,  the  lymphatic  vessels  are  prominent  and  may 
rupture,  allowing  the  chyle  to  flow  over  the  surface.  Inflammatory 
complications  are  common. 

Lymph  vulva  is  analogous,  in  the  female. 

Elephantiasis  (arabum)  is,  at  least  in  some  cases,  due  to  this 
filaria. 

Treatment.  Methylene  blue,  which  is  practically  harmless  to 
the  human  body,  is  said  to  be  destructive  to  the  filaria.  Surgery 
may  be  employed  for  the  deformities.  No  treatment  is  of  much 
value,  except  such  as  may  be  found  necessary  to  promote  the 
general  health  of  the  patient. 

Prophylaxis.  With  the  present  increase  in  communication  with 
tropfcal  countries,  a  guard  must  be  maintained  against  these  in- 
fectious agents.  Mosquitoes  must  be  eliminated ;  while  the  specific 
mosquito  may  not  live  with  us,  yet  it  is  never  safe  to  depend  upon 
future  occurrences  so  far  as  biological  laws  are  concerned.  Drink- 
ing water  Tnust  be  known  to  be  pure,  or  be  boiled,  especially  in 
tropical  countries.  The  presence  of  the  worms  in  the  urine  suggests 
suitable  disposition  of  this  source  of  contagion. 


TRICHINIASIS  597 

TRICHINIASIS 

(Trichinosis) 

This  is  a  disease  chiefly  affecting  the  muscles,  due  to  infection 
by  the  trichina  spirilis.  The  adult  worms  live  in  the  intestines; 
the  larvae  become  encysted  in  the  muscles.  The  diagnosis  rests 
upon  the  symptoms,  and  upon  finding  the  dead  adult  worm  in  the 
feces,  or  the  embryos  in  a  bit  of  muscle,  excised  for  the  purpose. 

The  pig  is  the  most  frequent  intermediate  host,  though  the  rab- 
bit, sheep,  dog,  rat,  mouse,  and  other  animals  may  harbor  the  worm. 
The  pig  may  eat  the  flesh  or  excreta  of  the  rat  or  another  animal ; 
the  larval  worms  become  fully  developed  in  the  stomach  and  in- 
testine of  the  pig,  produce  hundreds  of  thousands  of  ova,  and  then 
the  adult  worm  dies,  the  ova  hatch,  and  the  larvae  burrow  out  into 
the  body,  following  the  connective  tissues,  until  they  reach  muscle. 
They  become  encysted,  and  their  development  ceases  for  a  long 
time.  If  the  pig  is  killed,  the  flesh  eaten  without  being  thoroughly 
cooked,  the  same  story  may  be  repeated  in  the  body  of  a  human 
host.  The  end  of  the  story  varies,  for  the  human  body  is  rarely 
eaten  by  others,  and  human  excreta  is  usually  not  eaten  by  animals. 

No  definite  symptoms  are  manifested  unless  a  large  number  of 
the  parasites  are  eaten,  when  after  a  few  hours  or  days,  there  are 
symptoms,  of  gastro-intestinal  irritation  with  vomiting,  diarrhea, 
and  intense  sweating,  sometimes  varying  skin  eruptions,  and  abdom- 
inal pain.  Toward  the  end  of  the  second  week,  great  soreness  and 
stiffness  develops  in  the  muscles;  remittent  fever  appears;  and  a 
peculiar  edema  begins  in  the  face  and  spreads  to  the  skin  over  the 
affected  muscles.  Infection  of  the  respiratory  muscles  may  cause 
intense  dyspnea.  In  long  continued  cases,  the  patient  becomes 
emaciated  and  exhausted ;  the  typhoid  state  may  supervene ;  and 
death  ensue.  In  mild  cases,  the  symptoms  subside  in  about  two 
weeks.  The  disease  sometimes  appears  in  epidemics.  The  trichinae 
may  be  found  encysted  in  the  esophagus,  pericardium,  and 
lymphatic  glands. 

The  blood  shows  marked  eosinophilia — perhaps  above  30  per 
cent  of  the  total  leucocyte  count.  The  affected  muscles  are  tense, 
with  a  peculiar  rubbery  feeling  on  palpation.  Adult  worms,  some- 
times dead,  may  be  found  in  the  stools.  A  piece  of  an  affected 
muscle  may  be  excised  for  examination,  when  the  larvae  will  be 
found  coiled  up  within  the  muscle  fibers. 

Treatment.  When  contaminated  food  is  known  to  have  been 
eaten,  prompt  emptying  of  the  digestive  tract  is  urgent.  Vomiting 
may  be  compelled,  if  the  food  has  been  eaten  just  previously ;  urgent 
purgation,  even  with  drugs,  if  not  more  than  a  few  days  have  inter- 
vened since  the  food  was  taken.  Treatment  to  facilitate  the  flow 
of  bile  into  the  intestines  is  indicated  in  order  to  destroy  and  digest 
the  embryos  before  they  have  time  to  leave  the  intestinal  tract. 


598  NEMATODE  WORMS. 

After  the  embryos  are  once  encysted  in  the  muscles,  they  cannot 
be  dislodged  by  ordinary  means.  Hot  baths,  massage,  and  local 
manipulation  will  aid  in  securing  relief.  If  the  life  of  the  patient 
can  be  maintained  until  the  larvae  are  encysted,  the  prognosis  is 
good,  and  further  symptoms  are  not  to  be  expected.  If  early 
diarrhea  is  present,  the  prognosis  is  much  more  favorable,  as  by  it 
the  embryos  are  removed  from  the  system. 


UNCINARIASIS 

(European  hookworm  disease ;  miner's  anemia ;  tunnel  anemia  (or  cachexia)  ; 
brickmaker's  chlorosis;  Egyptian  chlorosis;  ankylostomiasis;  hook- 
worm disease) 
This  disease  results  from  infection  by  the  hookworm,  either  the 
European  type,  ankylostoma  duodenale,  or  the  American  form, 
Necator  Americanus.  The  parasite  is  voided  in  feces,  and,  under 
proper  sanitary  conditions,  dies.  When  feces  are  left  unprotected, 
as  is  the  case  among  the  negroes  and  the  poorer  whites  of  the 
South,  the  worms  with  the  dirt  may  be  spread  around  over  the 
ground,  and  become  unrecognizable.  Barefooted  persons  walking 
in  this  unclean  place  are  apt  to  have  abrasions  upon  the  soles  of 
the  feet,  and  the  worms  enter  the  skin.  Negroes  harbor  and  trans- 
mit the  disease,  but  suffer  few  or  no  symptoms.  The  skin  becomes 
inflamed,  and  this  is  called  "ground  itch"  or  "dew  itch."  The  worms 
are  carried  by  the  blood  to  the  heart  and  lungs,  are  carried  to  the 
pharynx  and  then  swallowed ;  pass  through  the  stomach  and  attach 
themselves  to  the  walls  of  the  duodenum  and  the  jejunum.  The 
worm  may  be  taken  with  food,  or  by  the  habits  of  the  "dirt-eaters." 
Occasionally  water  containing  the  parasite  is  used  in  washing, 
when  the  worm  gains  entrance  into  the  body  through  abrasions  of 
the  skin,  or  by  way  of  the  hair  follicles  or  sweat  glands.  The  worms 
not  only  feed  upon  the  blood,  but  their  presence  is  associated  with 
a  toxin,  either  from  their  own  metabolism  or  from  the  intestinal 
bacteria,  which  enter  the  system  by  way  of  the  wounds  made  by 
the  worm.  The  coagulability  of  the  blood  is  markedly  decreased, 
and  this  adds  to  the  anemia. 

Diagnosis.  A  considerable  number  of  parasites  must  be  present 
to  cause  any  symptoms.  At  the  stage  of  incubation  there  may  be 
gastro-intestinal  irritation  and  perhaps  fever.  In  an  advanced  con- 
dition, anemia  is  the  most  characteristic  feature ;  lack-lustre  eyes, 
dull  heavy  expression,  skin  of  a  dirty  muddy  hue  or  waxy 
white  is  present.  Children  are  stunted  in  growth  of  mind  and 
body.  As  the  disease  advances,  the  liver  and  spleen  enlarge  some 
what,  there  is  effusion  into  the  abdomen,  and  flatulent  distention 
producing  a  pot-bellied  appearance.  Palpitation,  shortness  of 
breath,  cardiac  bruits  due  to  severe  anemia,  and  edema  of  the  feet 
are  not  uncommon. 


UNCINARIASIS  599 

The  blood  shows  severe  secondary  anemia,  rarely  the  picture 
of  pernicious  anemia;  erythrocytes  may  be  less  than  one  million, 
but  are  usually  about  half  the  normal  count;  hemoglobin  may  be 
one-tenth  to  one-half  the  normal  amount.  Leucocytosis  is  not  com- 
mon ;  eosinophilia  is  marked.  The  coagulation  time  is  much  in- 
creased. 

The  feces  contain  the  ova,  sometimes  the  adult  worms.  In 
doubtful  cases,  small  masses  of  the  feces  may  be  incubated  for  one 
or  two  days,  when  the  worms  hatch  and  are  easily  recognized. 

Treatment.  The  removal  of  the  worms  with  the  least  possible 
harm  to  the  body  is  indicated.  Thymol  is  a  poison  which  is  not 
absorbed  into  the  body,  when  carefully  given,  and  which  is  very 
toxic  to  the  parasite.  The  dose  varies  from  eight  grains  for  a  child 
under  five  years  of  age,  to  forty-five  for  an  adult.  Thymol  is  soluble 
in  fats  and  in  alcohol,  so  that  for  a  day  before  thymol  is  given,  and 
for  from  one  to  four  days  after,  no  fats  or  alcohol  should  be  taken. 
The  best  way  to  avoid  poisoning  by  thymol  is  to  give  the  patient 
charcoal,  then  no  fat  or  alcohol  is  permitted  until  the  treatment  is 
completed.  When  the  stools  become  black,  the  thymol  is  given, 
on  an  empty  stomach.  A  purgative  is  given  a  few  hours  later. 
Enemas  should  be  used  very  freely,  in  order  to  facilitate  the  removal 
of  the  injured  or  poisoned  worms.  Another  dose  of  charcoal  is 
given,  and  when  the  stools  again  become  black,  the  patient  may 
return  to  his  ordinary  diet.  The  denial  of  fats  to  the  person  so 
thoroughly  accustomed  to  bacon  three  times  a  day  is  a  factor  met 
with  difficulty,  in  dealing  with  patients  of  the  ordinary  class  with 
the  disease. 

Prophylaxis  is  more  important  than  treatment.  The  most 
urgent  requirement  is  the  establishment  of  proper  methods  for  the 
disposal  of  feces,  and  the  enforcement  of  some  cleanly  habit  of 
defecation.  Negroes  present  the  most  difficult  problerh,  since  they 
harbor  the  worm  but  suffer  little  or  nothing  from  its  presence. 
The  ignorance  and  squalor  that  permits  promiscuous  defecation 
adds  greatly  to  the  difficulty  of  reeducation.  Mines,  brickyards, 
schools,  camps,  as  well  as  homes,  must  be  provided  with  latrines, 
and  the  disinfection  of  feces  made  compulsory.  Railroad  trains 
oflfer  remarkable  facilities  for  the  spread  of  such  diseases;  fortu- 
nately for  others,  the  persons  who  suffer  most  from  hookworm  do 
not  travel  very  much. 

Good,  strong  shoes  must  be  worn  in  the  infested  districts,  and 
the  feet  washed  often.  Great  care  must  be  taken  to  avoid  any  con- 
tact with  the  soil,  especially  in  places  possibly  contaminated. 
Drinking  water  must  be  known  to  be  pure,  or  else  must  be  boiled. 
The  entire  problem  is  simply  one  of  persistent  cleanliness. 


CHAPTER  LIII 
TREMATODES 

Trematodes  (Hole-borers)  are  so  called  because  they  enter  the 
bbdy  itself,  where  they  may  cause  fatal  symptoms.  They  are  rare 
in  man,  but  many  of  them -are  common  among  sheep  and  other 
animals. 

The  following  list  includes  the  more  common  of  the  flukes  which 
may  invade  the  human  body : 

Distomum  hepaticum.     (Liver  fluke;  Fasciola  hepaticum.) 

Distomum  pulmonale.  (D.  westermanii ;  fluke-worm  of  the 
lung;  Paragoninus  westermanii.) 

Distomum  lanceolatum.     (Dicrocelium  lanceolatum.) 

Distomum  hematobium.  (Bilharzia;  Hematobia  thecosomum; 
Gynaecophorus ;  Schistosmum  hematobium.) 

Distomum  sinense.  (D.  japonicum;  Schistosma  japonicum  or 
S.  cattoi ;  Apisthorchos  sinense.) 

Other  trematodes  which  may  be  found  causing  disease,  usually 
of  the  liver,  in  man  are :  Amphistoma  hominis ;  distoma  lanceola- 
tum ;  distoma  crassum ;  distoma  sibiricum  ;  and  distoma  spatulatum. 

These  are  all  obstinate  to  treatment  usually,  are  fatal,  or  persist 
through  life,  and  gain  access  to  the  human  body  through  uncleanly 
habits,  or  through  drinking  contaminated  water,  or  eating  contam- 
inated food. 

Distomum  Hepaticum  causes  "liver  rot"  in  sheep.  In  man  it 
aflfects  the  liver,  causing  great  bulging  of  the  hepatic  area,  with 
tense  abdominal  walls.  Emaciation,  diarrhea,  ascites,  and  death 
from  weakness  ensue.  Treatment  is  useless,  except  for  the  relief  of 
some  symptoms. 

The  life  history  of  this  fluke  illustrates  fairly  well  the  develop- 
ment of  all  flukes : 

"Let  us  start  the  history  with  the  mature  fluke  living  in  the  liver  of  the 
sheep.  Eggs  are  laid  in  large  numbers  in  the  biliary  passages,  and  these  find 
their  way  through  the  various  bile  channels  into  the  intestine  of  the  sheep. 
With  the  general  debris  of  the  intestine  these  eggs  are  expelled  from  the  body 
of  the  sheep.  Should  they  fall  upon  the  dry  earth,  they  soon  perish,  but  if 
by  chance  they  drop  into  the  water,  they  soon  develop  into  a  free  swimming 
ciliated  worm  which,  after  living  for  a  short  time  in  the  water,  enters  the  body 
of  a  snail.  Here  they  reproduce  themselves  asexually  and  ultimately  cause  the 
death  of  the  snail.  If  this  occurs  on  the  land,  the  young  worms  soon  perish, 
but  if  the  body  of  the  dead  snail  falls  into  water,  it  quickly  decomposes  and 
the  young  worms  are  set  free.  After  enjoying  their  freedom  for  a  short  time, 
they  enter  the  body  of  another  snail,  where  they  again  asexually  reproduce. 
This  second  snail  is  not  as  a  general  thing  killed,  but  it  crawls  up  on  the  stalks 
of  weeds  and  herb^e  growing  in  the  water  and  there  glues  itself  to  the  stem 

600 


DISTOMA  601 

of  the  plant.  If  by  chance,  this  stem  is  eaten  by  a  sheep  and  the  snail  swal- 
lowed, the  parasites  are  set  free  in  the  stomach  of  the  sheep  after  the  snail  is 
digested,  and  qujckly  passing  through  the  stomach  into  the  upper  intestine,  they 
make  their  way  to  the  liver,  there  to  begin  the  round  of  Hfe  again. 

"It  is  practically  certain  that  it  is  not  absolutely  necessary  for  the  fluke 
to  enter  the  body  of  its  second  host,  and  that  if  the  second  host  is  not  readily 
at  hand,  the  free  swimming  worms  at  length  attach  themselves  to  herbage 
growing  in  the  water,  and  in  this  form  they  may  be  directly  taken  into  the 
stomach  of  the  sheep  and  the  life  cycle  may  be  completed  in  this  way.  It  is 
also  quite  certain  that  if  they  should  be  inadvertently  swallowed  by  a  human 
drinking  the  water,  the  person  may  thus  become  infected  with  these  most 
dangerous  parasites.  For  that  reason  all  water  to  which  sheep  have  access 
should  be  regarded  with  great   "uspicion." — C.  A.  Whiting. 

Water  cress,  growing  in  streams  to  which  sheep  have  access, 
may  be  sold  for  food.  The  danger  of  eating  salad  made  from  this 
cress  is  evident. 

Distomum  pulmonale  causes  endemic  hemoptysis,  a  common 
disease  of  China,  Japan,  Korea,  and  Formosa,  and  occasionally  ob- 
served in  the  United  States.  The  embryo  is  probably  ingested  in 
water,  finding  its  way  to  the  lung  where  it  matures,  deposits  its 
ova,  and  develops  many  cysts  communicating  with  the  bronchi. 

The  symptoms  are  a  chronic  cough  with  bloody  expectoration 
containing  the  eggs,  occasional  hemorrhages,  and  frequently  a  sec- 
ondary anemia.  The  diagnosis  is  made  by  finding  the  ova  in  the 
sputum. 

Jacksonian  epilepsy  may  result  from  cerebral  invasion. 

Treatment.    No  treatment  is  reported  as  useful. 

Prognosis.  Uncertain  but  not  usually  fatal  unless  from  compli- 
cations. 

Prophylaxis.  The  only  precaution  is  to  be  sure  that  the  water 
source  is  uncontaminated  when  in  those  countries  where  this  dis- 
ease is  endemic  and  in  seaports  by  using  boiled  water. 


DISTOMA  HEMATOBIUM 

(Blood  fluke;  bilharzia  hematobia) 

Distomum  hematobium  causes  endemic  hematuria  or  distomiasis 
which  is  endemic  in  Egypt,  prevails  in  South  Africa,  Arabia,  Persia, 
and  west  coast  of  India,  and  imported  cases  are  known  in  Europe 
and  United  States.  The  male  is  about  one-half  inch  long,  cylin- 
drical, with  a  canal,  the  gynecophoric,  in  which  the  female  is  found. 
The  way  of  entrance  is  unknown,  but  is  prol^ably  by  water  or  on 
green  vegetables.  It  travels  to  the  portal  vein,  where  the  young 
specimens  are  found  uncoupled. 

The  males  bearing  the  females  creep  to  various  parts  of  the  body, 
especially  the  bladder^  urethra,  and  rectum ;  the  eggs  are  laid  in  the 
tissues  but  wander  and  escape  in  the  urine.     If  the  parasites  are 


602  TREMATODE  WORMS 

present  in  large  numbers,  they  give  rise  to  inflammation  and  hemor- 
rhages from  the  affected  mucous  membrane,  causing  endemic 
hematuria,  or  if  the  colon  be  affected,  diarrhea. 

These  parasites  may  cause  no  inconvenience.  The  most  fre- 
quent symptoms  are  irritability  of  the  bladder;  dull  pain  in  the 
perineum,  hematuria,  chronic  cystitis,  a  rather  slight  anemia,  and 
if  the  rectum  is  involved,  straining  and  tenesmus  with  the  passage 
of  blood  and  mucus.  In  severe  cases,  large  papillomata  and  chronic 
ulcerative  processes  may  be  present.  There  may  be  a  chronic 
vaginitis.  Few  symptoms  are  occasioned  by  the  presence  in  the 
portal  vein. 

The  complications  are  kidney  and  bladder  calculi.  Periurethral 
abscesses  and  perineal  fistulae  may  occur  in  chronic  cases. 

Diagnosis  is  readily  made  by  finding  the  ova  in  the  bloody  urine, 
in  the  blood,  or  in  mucus  from  the  stools. 
No  treatment  has  been  found  useful. 

•  Prognosis.  The  bilharzia  may  be  present  for  years  without 
producing  serious  damage.  In  slight  infections  the  symptoms  may 
disappear,  especially  in  children. 

Prophylaxis.  Carefulness  in  regard  to  the  drinking  water  and 
in  the  use  of  green  uncooked  vegetables  is  essential  when  there  is 
any  likelihood  of  infection. 

Quarantine.  A  laboratory  examination  of  the  stools  and  urine 
of  cases  even  slightly  suspected  when  from  these  countries  should 
be  made  at  the  immigration  ports  before  these  people  are  allowed  to 
land. 

HEPATIC  DISTOMIASIS 

This  disease  occurs  extensively  in  Japan,  China,  India,  and  some 
other  tropical  countries.  Imported  cases  have  been  reported  in 
Canada  and  the  United  States.  It  is  due  to  infection  by  the  Disto- 
mum  siense,  and  it  usually  affects  children,  especially  several  mem- 
bers of  the  same  family. 

The  symptoms  are  irregular  intermittent  diarrhea,  which  may 
or  may  not  be  bloody ;  gradually  enlarging  liver,  may  be  pain ;  an 
intermittent  jaundice ;  not  much  fever ;  after  two  or  three  years, 
dropsy,  anasarca,  and  ascites  develop,  and  the  patient  becomes  much 
reduced  and  progressively  anemic.  There  is  sometimes  a  localized 
epilepsy.    The  parasite  lives  in  the  intestinal  canal. 

Diagnosis  is  made  by  finding  the  ova  in  the  feces. 

Prognosis.  Ultimately  fatal.  A  transient  improvement  may  take 
place,  but  recurrence  comes  and  the  patient  dies  after  many  years 
of  illness. 


CHAPTER  LIV 
TAPEWORMS 

These  are  so  called  from  their  flat  series  of  proglottids.  These, 
usually  called  the  body  of  the  worm,  are  merely  hermaphroditic 
units.  The  entire  body  of  the  tapeworm,  properly  speaking,  is  what 
is  commonly  called  the  head. 

All  tapeworms  require  two  hosts  for  their  development.  In  the 
carnivorous  host  the  worm  secures  itself  to  the  intestinal  wall  and 
lives  upon  the  food  of  its  host.  The  proglottids  are  formed  and  are 
lost  in  the  feces.  These  are  voided  and  male  and  female  elements 
of  the  proglottid  unite,  either  during  the  passage  through  the  intes- 
tine or  shortly  after  being  set  free.  The  proglottids  of  some  species 
have  the  power  of  wandering  a  little  way.  Under  favorable  circum- 
stances some  herbivorous  animal  eats  the  vegetation  upon  which 
the  proglottids  have  been  deposited  and  the  eggs  are  carried  to  the 
stomach  of  that  animal.  The  eggs  hatch,  and  the  larvae  wander  out 
of  the  digestive  tract,  into  the  muscles  or  other  tissues  of  the  new 
host.  Here  they  encyst  themselves,  forming  what  is  called  a  "blad- 
der worm."  There  may  be  some  muscular  pain  and  fever  during 
this  invasion  of  the  herbivorous  host.  In  the  course  of  time,  this 
host  is  killed,  or  dies  and  is  eaten  by  some  carnivorous  animal.  The 
bladder  worms,  reaching  the  stomach  of  the  new  host,  are  set  free 
by  the  digestion  of  the  cyst,  and  go  on  their  further  development. 
They  attach  themselves  to  the  wall  of  the  carnivorous  host,  form 
proglottids,  and  follow  in  the  steps  of  their  ancestors. 

In  the  human  being,  the  worm  is  usually  brought  into  the  body 
with  poorly  cooked  meat.  The  use  of  contaminated  water,  or  the 
uncleanly  habits  of  children  who  are  allowed  to  have  animal  pets, 
may  permit  the  eggs  to  be  carried  into  the  body,  and  the  bladder 
worm  type  may  thus  be  found  in  the  human  body.  Vegetables 
which  have  been  fertilized  with  excrement,  or  irrigated  with  sew- 
age, may  also  be  a  source  of  danger.  When  the  human  being  acts 
as  the  herbivorous  host,  the  later  development  of  the  bladder  worm 
is  prevented,  since  the  human  body  rarely  serves  as  food  for  carnivo- 
rous animals. 

Tapeworms  are  avoided  by  cooking  all  meat  very  thoroughly. 
Larvae  are  avoided  by  cooking  vegetables  Whose  origin  is  not 
known  to  be  wholesome. 

The  most  common  of  the  human  tapeworms  are : 

Bothriocephalus  latus.  (Tenia  lata;  Broad  tapeworm; 
Dibothriocephalus  latus ;  Tenia  grisea.) 

Tenia  nana.    (Hymenolepis  nana.) 

603 


604  TAPEWORMS 

Tenia  flavopunctata.    (Hymenolepis  diminuta  or  flavopunctata.) 
Tenia  lanceolata. 

Tenia  solium.    (T.  vulgaris ;  T.  cucurbitina ;  Pork  tapeworm.) 
Tenia  saginata  or  medio-canellata.     (Beef  tapeworm.) 
Tenia    ecchinoccus,     (Bladder-worms;     Hydatid    ecchinoccus; 
Cysticercus.) 

Tenia  elliptica.    (T.  cucumerina;  Dipylidium  caninum.) 

Diplogonoporus  grandis  and  sparganum  mansoni  are  found  in 
the  Philippines,  and  may  invade  this  country  later.  Tenia  confusa 
(Ward)  has,  so  far,  been  found  only  in  Nebraska. 

Bothriocephalus  latus  is  the  largest  tapeworm  known,  being 
sixteen  to  thirty  feet  long  by  one  inch  wide,  with  3,000  to  4,000 
segments.  The  head  is  small,  oval  or  club-shaped,  with  a  longi- 
tudinal groove  on  each  side.  It  has  no  proboscis  suckers  nor  hook- 
lets.  Each  segment  is  bi-sexual.  The  intermediate  host  is  some 
fish,  as.  pike  or  turbet.  It  is  found  in  Switzerland,  northeastern 
Europe,  and  Japan,  and  among  the  Finns  in  the  United  States. 

The  general  symptoms  of  Bothriocephali  and  Teniasis  are:  re- 
flex ^disturbances  as  itching  of  the  nose  and  anus,  colicky  pains, 
attacks  of  diarrhea,  voracious  appetite,  mental  trouble  as  melan- 
cholia, convulsions  and  occasionally  reflex  vomiting,  loss  of  flesh, 
vertigo,  grinding  the  teeth  at  night,  and  gastro-intestinal  irritation. 

The  anemia  due  to  this  invasion  is  particularly  severe.  It  shows 
a  blood  picture  which  is  often  not  to  be  distinguished  from  that 
of  pernicious  anemia. 

Tenia  flavopunctata  is  about  a  foot  long,  and  the  eggs  are  larger 
than  those  of  the  nana.  The  head  is  small,  clubbed  and  unarmed. 
The  larvae  develop  in  the  Lepidoptera. 

Tenia  lanceolata  is  31  to  130  mm.  long.  The  head  is  globular, 
very  small,  the  rostellum  is  cylindrical  with  a  crown  of  eight  hooks. 
The  ova  have  three  envelopes. 

Tenia  solium,  or  pork  tapeworm,  is  more  common  in  Europe. 
It  is  six  to  twelve  feet  long,  with  200  to  400  proglottids.  The  head 
has  a  projecting  rostellum,  upon  the  summit  of  which  are  30  to  40 
booklets  and  four  lateral  suckers.  The  uterus  has  about  twelve 
horizontal  ramifications  to  a  segment.  The  larvae  are  the  simplex 
scolex,  which  form  the  measle  of  pork  (cysticercus  cellulosae).  The 
intermediate  host  is  the  pig. 

Tenia  nana  is  from  two  to  three  centimeters  long  by  one-half 
millimeter  broad  with  about  two  hundred  segments.  The  head  has 
four  round  suckers  at  the  base  of  the  rostellum  which  can  be  in- 
verted. The  intermediate  host  is  unknown.  It  is  especially  com- 
mon in  children. 


HYDATID  DISEASE  60S 

Tenia  elliptica  is  five  to  eight  inches  long  and  one-fourth  inch 
broad.  The  worm  spends  its  larval  stage  in  the  bodies  of  dog-fleas 
and  the  adult  stage  in  the  intestines  of  the  dog.  Children  playing 
with  infected  dogs  can  very  readily  become  infected  with  the  mature 
worm,  or  they  may  swallow  the  fleas. 

Tenia  saginata,  or  beef  tapeworm,  is  the  most  common  in  this 
country.  It  is  fifteen  to  twenty  feet  long,  with  a  small  head  sur- 
mounted by  four  powerful  sucking  cups,  but  no  rostellum  or  hook- 
lets.  The  uterus  is  finely  branched.  The  adult  worm,  strobile,  lives 
in  man  and  the  embryo  or  scolex  lives  in  cattle.  The  larvae  are 
cysticercus  bovis. 

Treatment.  The  diflferent  kinds  are  diflferently  susceptible  to 
suljstances  poisonous  to  them,  but  often  not  poisonous  to  the  host. 
The  drugs  usually  used  to  kill  them  include  santonin,  extract  of 
"male  fern,  thymol,  etc.  A  physical  agent  is  found  in  flaxseed  and 
pumpkin  seed,  which  mechanically  loosens  the  head  and  permits  its 
elimination. 

In  any  case,  a  day  or  a  few  da5^s  of  fasting  is  required  in 
order  to  remove  the  protecting  food  material  from  the  worm,  and 
to  cause  its  weakening.  Free  flushing  of  the  colon  is  useful,  in 
order  to  encourage  intestinal  activity.  Free  drinking  of  water 
serves  the  same  purpose,  and  also  it  keeps  up  the  strength  of  the 
patient.  The  feces  must  be  watched,  in  order  to  be  sure  that  the 
worm  is  thoroughly  removed. 

A  full  cellulose  diet,  with  fasting  every  other  day,  plenty  of 
water  and  plentiful  washings  of  the  colon,  sometimes  lead  to  the 
evacuation  of  the  worm,  with  no  other  anthelmintic. 

Persons  afflicted  with  tapeworm  should  thoroughly  sterilize  the 
stools  and  the  clothing,  carefully  avoiding  contamination  of  them- 
selves or  others. 

HYDATID  DISEASE 

Tenia  echinococcus  is  the  smallest  of  human  tapeworms.  It 
is  less  than  half  an  inch  long,  and  has  four  segments,  of  which  the 
last  is  mature.  In  this  worm,  the  man  acts  as  the  vegetarian  host; 
the  dog,  rarely  other  domestic  animals,  acts  as  carnivorous  host. 
The  ova,  embryos,  or  proglottids  are  voided  in  the  excrement  of 
the  dog,  and  are  dried  and  blown  by  dust,  or  the  fecal  masses  are 
handled  by  man,  or  in  some  other  way  the  microscopic  organisms 
reach  the  food  of  man,  and  are  swallowed.  The  young  larvae  un- 
dergo further  development,  push  their  way  through  the  walls  of 
the  alimentary  tract,  and  become  encysted  in  other  organs  of  the 
body.  These  cysts  grow  to  considerable  size ;  and  the  parasites 
multiply,  producing  daughter  cysts;  the  ultimate  lobulated  cyst 
forms  a  hard  tumor,  filled  with  a  fluid  which  contains  the  scolices 
and  booklets  of  the  parasite.    After  multiplication  beyond  the  nutri- 


606  TAPEWORMS 

tive  possibilities,  the  parasites  may  die,  the  cyst  become  thickened, 
the  fluid  dries,  and  ultimately  only  a  hard,  usually  harmless  tumor 
is  left.  The  wall  of  the  cyst  may  rupture,  in  which  case  serious 
symptoms  are  to  be  expected.  Infection  with  pyogenic  bacteria 
may  cause  abscess  formation. 

Diagnosis  is  made  from  finding  hooks  or  scolices  in  the  aspirated 
fluid. 

The  liver  is  far  more  often  affected;  the  lungs  and  kidneys  less 
often,  and  the  brain  and  other  organs  only  very  rarely. 

The  only  treatment  is  the  surgical  removal  of  the  cyst,  when 
this  is  accessible. 

Prophylaxis.  The  disease  is  easily  avoided.  Dogs  ought  not  to 
be  permitted  to  live  except  under  supervision.  Those  who  care  for 
dogs  should  keep  them  away  from  human  food,  and  should  be 
cleanly  in  their  habits.  Every  bit  of  fecal  material  should  be  con- 
sidered potentially  dangerous.  Dogs  may  be  protected  from  infec- 
tion by  feeding  them  only  meat  that  is  known  to  be  free  from 
infection,  and,  for  the  most  part,  meat  that  has  been  well  cooked. 
Dogs  are  too  dangerous  to  be  allowed  to  play  with  small  children ; 
if  larger  children  are  permitted  to  play  with  them,  the  most  eternal 
vigilance  must  be  observed  in  regard  to  cleanliness  and  health. 


INDEX 


Abdomen,   enlarged   in — 

anthrax    

ascites    

cretinism    

enteritis    80 

constipation    61, 

gastro-enteroptosis    

hookworm    disease 

leukemia 

liver,  diseases  of 

pancreatitis     

pericarditis    callosa 

peritonitis    

rachitis     

(See  also  ascites  and  flatulence) 
Abdomen,  nodules  in  cancer 

rigid,  in  peritonitis 

appendicitis 

pain,  see  Pain,  abdomen 

veins  distended,  in  ascites 

Abdominal  typhus 

Abortion,  in  cholera 

relapsing  fever    

syphilis 

typhoid   479, 

yellow  fever 

Abscess  or  abscesses — 

amebic   

in  variola    

in  vaccination    

Abscess  or  abscesses  of — 

appendix    

bowels    

brain    

heart     .. .  .> 

liver    

lungs    

neck,  angina   Ludovici 

in  scarlet  fever 

pharynx  

pleura  

rectum   

teeth   

tonsils     

Acentonuria,  in — 

acute  articiilar  rheumatism.... 

autointoxication    

diabetes  mellitus    

fevers,  q.  v. 

typhoid   

Aching,  see  pain 


Achylia,  gastrica  nervosa 33 

538      Acidity,  gastric,  diminished  in 

128  cancer    47 

301      Acidity,  in  gastric  dilatation 51 

,  87  (See  Hydrochoric) 

77      Acidosis    284 

69  in  bronchial  asthma 210 

598      Acromegaly    304 

242      Actinomycosis     534 

109  brain 535 

124  intestines 535 

138         jaw 535 

130         lung  535 

287         skin  535 

Adenoids 190 

133      Addison's  disease  306 

130      Adrenals,  disease  of 306 

96      Adhesions,  cause  of  intestinal 

obstruction    72 

129  Adiposa  dolorosa   290,  291 

478  tuberosa    291 

576      Adiposity,  in — 

521  brain  tumor  388 

525  hypophysis  disease    305 

480  (See  also  obesity) 

574     Aerophagia    34,  35 

Agoraphobia    401 

112      Ague  cake  313,  581 

543      Ainhum   568 

547     Air,  in  pericardium 140 

pleural   cavity    225 

96      Alcoholism 323  et  seq. 

93      Aleppo  boil    587 

389      Albuminuria,  in 245 

141  arteriosclerosis    173 

111  autointoxication    66 

221  bronchitis    207 

197  delirium  tremens   325 

552  dilatation    of   heart 145 

196  diabetes  mellitus    281 

220         erysipelas    515 

101  fevers,  usually,  q.  v. 

26  gall-stones 120 

190  hepatic  disease    114 

pancreatic  disease 124,  125 

518         tuberculosis    468 

66  valvular  lesions   159  et  se(j. 

281  yellow  atrophy  10/ 

Alopecia,  after  typhoid 480 

480  syphilis    522 

Alpine  scurvy  333 

607 


608 


INDEX 


Alveolar  ectasis   219' 

Amaurosis,  hemolytic  anemia 236 

Amaurotic    family    idiocy 382 

Amblyopia,  toxic  433 

Ameba,  in  abscess  of  liver 112 

dysentery    589 

Ameba  hystolytica 112 

Amentia — 

in    hemiplegia    of   children 384 

Amyloid,  degeneration  in  malaria. 584 

syphilis    522 

kidney    259 

liver    114 

Amyotrophic  lateral  sclerosis 367 

Anaphylaxis    321 

Anemia    229 

Addison's    235 

aplastic    244 

blastomycotic    239 

Burns   230 

costogenic    230 

hemolytic    235 

idiopathic    .». 235 

infantile 238 

pernicious  primary    235 

secondary   229 

splenic   238 

Anemia,  secondary  in — 

articular  rheumatism 278 

aortic  regurgitation 166 

arsenicism  331 

blood  fluke  disease 602 

cancers,  q.  v. 

chloroma    239 

fevers,  q.  v. 

hookworm  disease  598 

lead   poisoning    329 

malaria    584 

mercurialism  330 

scorbutus    289 

splenomegaly 586 

thread  worms   594 

tuberculosis    461 

ulcer,  gastric   45 

Anesthesia,  in — 

leprosy    475 

meningitis 342 

myelitis    358 

neuritis ,  .430 

of  intestines  55 

Aneurysm — 

axial    175 

dissecting    175 

false    175 

miliary 175 

Aneurysm  of  heart  or  valves 149 

aorta    175 

Aneurysm — treatment  of .177 

Aneurysmal  varix 175 

Angina  catarrhalis  195 


Angina,  glandular  fever 564 

Angina   Ludovici   197 

Angina  pectoris  ISO 

simplex   195 

sine  dolore  151 

vera 151 

Vincent's   198 

Angina  pectoris,  in — 

fatty  heart   144 

aortic    regurgitation    165 

arteriosclerosis     173 

Angiocholitis   115 

Angioneurotic  edema   316 

Ankle   drop    329 

Anorexia   nervosa    34 

(See  appetite) 

Anosmia    433 

in  fifth  nerve  lesion 438 

Anthracosis    222 

Anthrax    537 

Aorta,  small,  in — 

epilepsy   409 

regurgitation    165 

stenosis    166 

Aortitis    159 

Apathy,  brain  tumor 388 

Aphasia,  in — 

apoplexy   375 

arteriosclerosis    173 

brain  tumor   388 

hemiplegia  of  children 384 

Aphonia,  aortic  aneurysm 176 

pericarditis    135 

Aphthous  fever    534 

Aplastic  anemia   244 

Apoplectic  habit  374 

Apoplexy    373 

confused  with  alcoholism 378 

delayed   374 

heat 317 

ingravescent     376 

pulmonary 216 

splenic    537 

spinal   355 

Apoplexy,  in — 

nephritis    255 

purpura    310 

Appendicitis    95 

confused  with  intestinal 

actinomycosis    535 

fulminating 96 

pseudo 97 

Appetite,  lost  or  variable,  in — 

autointoxication    65 

gastro-intestinal  diseases  ..33-100 

hepatic    diseases    105-112 

hysteria    394 

lead  poisoning  328 

nephritis    252 

tuberculosis    467 


INDEX 


609 


perverted  in — 

chlorosis    233 

hookworm  disease  598 

hysteria    394 

voracious,  after  typhoid 480 

tapeworm  disease 603  et  seq. 

Aptyalism    26 

Aprosexia    190 

Argyll-Robertson  pupil  437 

in  para-syphilitic  diseases 

Arrhythmia   155 

Arsenicism   330 

Arteries,  coronary,  disease  of 149 

Arteries,  hardening 172 

Arterio-capillary    fibrosis    172 

Arteriosclerosis 172 

alcoholism    323 

syphilis    523 

interstitial  nephritis   255 

Arthralgia,  lead  poisoning 329 

Arthritis,  acute  278 

chronic  progressive 276 

deformans    276 

gouty    272 

hypertrophic   276 

purulent,  in  variola 543 

rheumatoid  276 

Arthritis,   in   influenza 490 

Malta  fever  * 572 

pneumonia    505 

paratyphoid   fever    486 

scarlet  fever  554,  555 

syphilis   523 

Arthropathy,    chronic    infectious.  .276 

Ascaris   lumbricoides    595 

Asiatic  cholera   575 

Ascites  128 

cardiac  lesions    167 

fluke  disease  600-602 

liver  diseases    109-112 

nephritis 249 

pancreatic  disease   126 

pericarditis  callosa 138 

peritoneal   diseases    133 

splenic  anemia  238 

Asphyxia,  in  acute  thyroiditis 296 

goiter    297 

hydrophobia    531 

local,  Raynaud's  disease 316 

Asthenia,    generalis    68 

obstruction  of  bowel 74 

Asthma,  anaphylactic  321 

bronchial    210 

cardiac    157 

in  fatty  heart   144 

spasmodic   210 

Asthma,   in   aneurysm    176 

bronchitis    208 

gout  272 

mouth  breathing   191 


whooping   cough    492 

vagotony  445 

Ataxia,   cerebellar    .389 

hereditary  spinal   370 

in   tabes   dorsalis 345 

in  tabo-paralysis 349 

Atelectasis    218 

Atheroma   172 

Athetoid  movements,  in — 

cerebral  meningitis   341 

cerebral  hemorrhage 376 

hemiplegia  of  children 384 

lenticular  disease  387 

tumors  of  basal  ganglia 389 

Athetosis,    primary , 452 

Athletic  heart,*aortic  regurgitation  165 

Atresia,  anj   72 

Atrophia  myotonia   451 

Atrophy  of — 

auditory  nerve,  in  tabes 441 

face .451 

muscles    451 

in  lead  poisoning  '. .  .329 

pseudohypertrophic     450 

optic  nerve 435 

testicles,  after  mumps 563 

Auditory  disturbances,   cerebellar 

disease 389 

Auditory  nerve,  lesions  of 440 

Aura  of  epilepsy ^ 410 

Auricular  fibrillation 156 

Autumnal  catarrh   186 

Awkwardness,  in   children — 

chorea 415 

spinal  ataxia    370 

Baby,  emaciated  at  birth,  syphilis. 525 

Bacilli  in  urine,  typhoid 481 

Bagdad   boil    587 

Backache,  see  Pain  in  back 

Banti's  disease   238 

Barlow's  disease 289 

Basal  ganglia,  hemorrhages  of.... 376 

Basal  tumors  389 

Basedow's  disease  297 

Basophilic  granulation,  lead 

poisoning    329 

Basophilic  stippling,  hemolytic 

anemia    236 

Bed  sores,  in  neuritis  431 

spinal  meningitis    341 

syringomyelia 360 

Bed   wetting    265 

Beef  tape  worm 605 

Belching — 

in  dilatation  of  stomach 50 

gastric  neuroses 33-35 

gastritis   42 

Bell's  palsy 439 

Bends  362 

Bergeron's  chorea  421 


610 


INDEX 


Beri-beri   566 

Biermier's  disease  ' 235 

Bil©  ducts,  diseases   of 115 

Bile'  in  urine — 

in  hypertrophic  cirrhosis 110 

jaundice 104 

(See  jaundice) 

Bilharzia   hematobia 601 

Biliary  calculi   1 18 

cirrhosis 109 

colic J..  119 

confused  with  pancreatic  calculi ...  127 

Biliousness  105 

Bilious   fever    38,  582 

Biscra  button   587 

Black  smallpox .*. 542 

Black  vomit  573 

Blackwater  fever  583 

Bladder,  irritable,   proctitis 101 

Blastomycotic  anemia 239 

Bleeder's  disease   311 

Bleeding    from    mouth,    ulcerative 

stomatitis    18 

Bleeding  from  nose,  in  cirrhosis  of 

liver  108 

Blepharospasm   419 

Blindness,  in  acromegaly   304 

spinal  meningitis 508 

amaurotic  idiocy    382 

leprosy 475 

nephritis    255 

optic  nerve  lesions 433  et  seq. 

snow  delirium 319 

syphilis  ., 525 

Blisters,  in  stomatitis 20 

Blood,  affected  by  toxins,  gout. . .  .273 

autolysis,  of,  in  pneumonia 503 

bacillemia,  in  plague. .  .• 530 

cells,  degenerated  types  69 

in  anemias    277  et  seq. 

autointoxication    66 

yellow  atrophy 107 

cells,  formation  of   227 

cells,  increased  in  diphtheria. ..  .496 

polycythemia    239 

coagulation  time  increased,  in — 

anemias 229  et  seq. 

hemophilia    311 

jaundice 104 

gallstones ., . .  120 

diseases  of  227 

excess  of  fibrin,  acute  articular 

rheumatism 518 

filaria 595 

Blood  changes,  in — '• 

aplastic  anemia .244 

chlorosis    233 

costogenic  anemia 231 

epilepsy    410 

hemolytic  anemia  2Z6 


Hodgkins'  disease   244 

hysteria 394 

lead  poisoning  329 

lymphatic  leukemia    240-241 

malaria 584 

neurasthenia 402 

pellagra   334 

rachitis 287 

relapsing  fever 521 

scarlet   fever    552 

splenomedullary  leukemia 241-242 

typhoid 481 

Blood  in  feces  or  stools — 

cirrhosis  of  liver   108 

duodenal  ulcer 45 

enteritis 84,  87,  92.  100 

obstruction    73,  77 

Blood,  in  urine — 
diseases  of  kidney  and  bladder. 245-269 
(See  also  hematuria) 

Blood  in  vomitus — 

(See  hematemesis  and  hemoptysis) 

Blood  fluke 601 

Blood  pressure,  falling  with  fever, 
in  typhoid 484 

Blood  pressure,  low — 

in  Addison's  disease .307 

cholera 576 

cretins    301 

diphtheria   496 

gastro-enteroptosis 69 

heat  exhaustion  318 

myxedema 302 

pneumonia,  early 501 

typhoid 481 

Blood  pressure,  increased  or  high,  in — 

acute  articular  rheumatism  518 

arteriosclerosis    173 

impending  cerebral  hemorrhage. . .  .375 

interstitial  nephritis  255 

gout    272 

Blood    pressure,    varying,    autoin- 
toxication      65 

Blood  vessels,  diseases  of 171 

Bloody  flux    94 

Boils,  in  diabetes  mellitus 279 

Bones,  deformed,  in — 

acromegaly   304 

disease  of  gonads  308 

osteitis  deformans   305 

rachitis  286 

syphilis  526 

Bones,  erosion  of,  by 

actinomycosis   535 

aneurysm     176 

tuberculosis    473 

Bones,  fragile,  in — 

hemolytic  anemia   237 

hypophysis  adiposity  306 

rachitis 286 


INDEX 


611 


S3^mgomyelia 360 

Bone  tumors,  painful,  in  syphilis.  .523 
Bones,  undeveloped,  in  cretins. ..  .301 
Bony  lesions — 

as  cause  of  muscular  cramp  or 

contractions  407,  447 

as  localizing  factors  in  nervous 

diseases  350,  352 

in  acute  infections  454 

etiology,  many  diseases 
Borborygmi,  in  peristaltic  unrest..  35 

in  acute  enteritis   90 

Bothriocephalus    604 

Bradycardia    154 

in  chronic  myocarditis 142 

typhoid 480 

Brain,  diseases  of 371 

abscess   389 

actinomycosis  535 

embolism  376 

in   endocarditis    159 

mitral   stenosis 164 

fever 506 

syphilis 525 

tumors    387 

Break-bone  fever  570 

Breast  pang  150 

Breath,  fetid,  in — 

acute    tonsillitis    188 

constipation    61 

scorbutus  289 

Breath,  foul,  in — 

mumps   562 

intestinal    autointoxication....  65 

stomatitis 18 

heavy,  in — 

acute  gastritis   38 

stomatitis     17 

oflFensive,  in — 

gout    271 

stomatitis    20 

sweetish,  like  apple-blossoms,  in 

diabetes   mellitus    280 

Breathing,  difificult,  see  dyspnea    ■ 
expiratory  moan,  in  broncho- 
pneumonia     21 

noisy,  in  diphtheria 495 

rattling,  labored,  pulmonary 

edema     217 

stertorous — 

in  alcoholism  324 

apoplexy    375  • 

wheezing,   in   emphysema 220 

(See  Cheyne-Stokes  respirations) 

Brickmaker's  chlorosis 598 

Brill's  disease   486 

Broadbent,  phenomena  of 138 

Bronchi,  diseases  of  205 

Bronchial  asthma 210 

Bronchial  catarrh   205,  206 


Bronchiectasis  209 

Bronchiolitis 206 

Bronchitis    205 

capillary    212 

in  diphtheria    496 

emphysema    219 

mouth   breathing    191 

relapsing  fever    521 

tricuspid  regurgitation 167 

Bronchorrhagia    215 

Broncho-pneumonia    212 

in  anthrax  538 

Bronchorrhea    207 

in  mitral  stenosis   .'164 

Broken-wing  fever 570 

Bronzed  diabetes   110 

Bronzing  of  skin,  in — 

Addison's  disease 307 

pituitary  disease   304 

(See  skin) 
Bruises,   spots   resembling   in — 

purpura    309 

Bubo,  parotid    27 

Bubonic  plague 529 

Buccal    psoriasis    2Z 

Bulbar  palsy   366 

Bulimia    34 

Bullae,  purpura 310 

Burning,  of  the  feet,  in  acute 

gastritis   38 

Cachexia,  in  bronzed  diabetes. ..  .110 

cardiac  neoplasms 149 

chloroma   239 

Hodgkins'  disease 244 

hemolytic  anemia 236 

leukemia    240 

malaria   582,  584 

morphinism    ^ 326 

pellagra   334 

pineal  disease 308 

saturnism .• 328 

scorbutus 289 

strumipriva 301 

tetany  304 

(See  cancer  and  emaciation) 

Caisson  disease ;362 

Calculus,   biliary 118 

bronchial    222 

intestinal 77,  92 

pancreatic 127 

renal   258 

Calcium  oxalate  in  urine,  chronic 

gastritis    43 

Cancer  aquaticus   20 

Cancer  cells  in  vomitus 49 

Cancer,  of  esophagus 30 

gall-bladder    122 

intestines  78 

kidney    262 

liver    112 


612 


INDEX 


lungs  222 

mouth  20 

pancreas    126 

peritoneum   133 

prostate   ^ 269 

stomach   46 

Cancrum  oris 20 

Caput  medusae   108 

Cardiac  aneurysm   149 

asthma  1 57 

dilatation  145 

disturbances,  in  nerve  lesions  .  153,  444 

h3T)ertrophy   146 

injuries    148 

misplacements   148 

,  neoplasms   149 

neuroses 153 

Carditis    141 

Cardiosclerosis    141 

Cardiospasm  32 

Carriers,  of — 

diphtheria   494 

sleeping  sickness  589 

spinal  meningitis  507 

tropical  dysentery 569 

typhoid 485 

Carsickness    315 

Casts,  in  sputum,  fibrinous 

bronchitis    i 209 

urinary,  in — 

autointoxication    66 

fevers,  q.  v. 

nephritis  247  et  seq. 

Cataract,   in    diabetes    mellitus. . .  .280 
Catarrh  and  Catarrhal — 

appendicitis 95 

bronchitis    205 

cholangitis 115 

cholecystitis    117 

cystitis   266 

enteritis    79,  90 

esophagitis 29 

gastritis T 38,  41 

in  arsenicism 331 

laryngitis  199 

nasal  183 

nephritis    248 

pharyngitis    195 

proctitis   101 

rhinitis   183 

stomatitis    16 

Cellulitis  of  neck 197 

Cephalic  trismus 532 

Cephalodynia  274 

Cerebellar  hemorrhage 376 

tumors   389 

Cerebral  anemia   372 

edema  m 

embolism  376 

diplegia    385 


hemorrhage 374 

localization    of    375 

in  hypertrophy  of  heart 147 

in  whooping  cough  492 

hyperemia   372 

meningitis   339,  341,  506 

paralyses  of  children  382 

syphilis 524 

thrombosis    377 

Cerebral  type,  malignant  endocar- 
ditis,    confused     with     cerebral 

meningitis    160 

Chalicosis    222 

Chapping  of  lips 24 

Character,  epileptic  413 

Charcot's   joint 346 

Charbon   537 

Cheilitis 24 

Chest,  deformities,  in  rachitis 287 

barrel   ..220 

Cheyne-Stokes  breathing,  in — 

fatty  heart 144 

fermental  enteritis,  of  children 83 

spinal  meningitis 507 

Chicken    pox     548 

Child-crowing    203 

Child,  retarded  growth,  congenital 

syphilis   526 

Chill,  see  fever 

Chin,  pain,  in  tongue  diseases 21 

Chloroma    239 

Chlorosis 232 

Chlorotic  cells 233 

Choked   disk    434 

in  brain  tumor   388 

Cholecystitis  117 

Cholelithiasis  118 

Cholera    575 

Asiatic   575 

infantum   82 

morbus  93 

nostras 93 

sicca    576 

typhoid  576 

Choleraic  symptoms  acute  food 

poisoning   336,  337 

Choleriform    diarrhoea    82 

Cholerine    576 

Cholesterin,    in    gall-stones 118 

Chorea    414,  421 

in  acute  rheumatic  fever   518 

scarlet  fever 556 

typhoid 480 

Choreic  hemiparesis,  children 385 

Choreiform  movements,  in  cerebral 

hemorrhage   376 

Choroiditis,   syphilis    522 

Chyluria,   in   filariasis 596 

pancreatic  c?ncer   * 126 


INDBX 


613 


Cicatrix,  cause  of  intestinal 

stricture    72 

Circulatory  disturbances,  in 

chronic  prostatitis   268 

Cirrhosis  of  liver 108 

alcoholic    ? . .  108 

atrophic   108 

biliary 109 

hypertrophic • 110 

Laennec's    108 

multilocular    108 

portal   108 

unilobular    110 

Cirrhosis  of  the  liver  in  lenticular 

disease 387 

polyserositis    140 

Cirrhosis   of   kidney 253 

lungs  470 

spleen  312 

Claustrophobia    401 

Clay  eating,  in  chlorosis 233 

Climate,   in    tuberculosis 463 

Clergymen's    sore    throat 198 

Clownish   movements,   progressive 

chorea    416 

Clubbed  fingers,  children,  with 

mitral   lesion    163 

Coagulability  of  blood,  diminished, 

in  jaundice   104 

Cocainism    328 

Coccygodynia    428 

Coeliac   affection    89 

Coffee   grounds  and  vomitus,  in 

gastric  cancer   48 

Cold  hands,  autointoxication 65 

Cold-sense,  lost  in  syringomyelia. 360 

Colica  pictonum   328 

Colic,  biliary   116,    119 

Devonshire   328 

differential   diagnosis  of  types..   57 

painter's     328 

Colic,  in — 

fermental  enteritis  of  children..  82 

lead  poisoning 328 

morphinism    Z26 

mucous    colitis    56 

potato  poisoning    2i26 

Colitis,  acute  90,  94,  100 

mucous    56 

Collapse,    cholera     576 

Collapse,  in  acute  dilatation 50 

acute   enteritis    84,  91 

acute  food  poisoning   Z2i7 

acute  gastritis  40 

acute  myocarditis  141 

acute  pancreatitis 123 

appendicitis    96 

biliary   colic 119 

cholera  morbus 93 

malaria    583 


obstruction    •. TZ 

relapsing  fever   521 

strangulation    75 

tuberculous   meningitis    470 

variola    542 

yellow  fever  574 

(See  prostration) 

Collapse  of  lung 218 

Collateral   circulation   for   portal..  108 

Colon,  dilated,  in  epilepsy 409 

Coma,  in — 

acute  articular   rheumatism 518 

alcoholism    323 

apoplexy 375 

cerebral  anemia    372> 

cholera  576 

cirrhosis  of  liver 109 

diabetes  mellitus    280 

disseminated  myelitis   349 

enteritis  of  children 84 

heat   injuries    316 

jaundice 104,  528 

lead  poisoning  329 

malaria 583 

milk  sickness 536 

mushroom   poisoning    336 

myocarditis    141 

pulmonary  edema 217 

scarlet    fever    551 

sleeping  sickness    589 

spinal  meningitis    508 

tuberculosis 469 

Coma,  sudden,  in  acute 

morphinism   326 

Coma,   vigil,   in   typhoid 480 

typhus    487 

Compression  of  spinal  cord 358 

Congenital  dilatation  of  intestine. .  71 

Congestive  fever    583 

Congestive  chills   583 

Conjunctiva,  yellow,  in  jaundice.  .104 

in    gall-stones    119* 

Conjunctivitis,  in  acute  rhinitis.  .  .183 

hay  fever  187 

influenza    489 

measles    557 

Constipation    60 

nervous    56 

in  acute  articular  rheumatism 517 

costogenic  anemia    231 

ascites    129 

dilatation  of  heart  145 

gastro-intestinal  diseases  ...42  et  seq. 

hemolytic  anemia  235 

hepatic  .diseases   105  et  seq. 

hydronephrosis    260 

malaria 582 

milk  sickness  536 

morphinism    326 

scorbutus  289 


614 


INDEX 


typhus    , . .  ,486 

vagotony    445 

Contracted   kidney 253 

Convulsions,  in  biliary  colic 119 

cerebral  leptomeningitis   341 

children's  diseases   416 

broncho-pneumonia    213 

enteritis   80,  83,  87 

hemiplegia 384 

epilepsy    410 

heat  apoplexy    317 

hydrophobia   531 

infantile  paralysis 511 

malaria 583 

milk  sickness  • 536 

mushroom  poisoning    336 

nephritis  250,  255 

scarlet  fever 556 

sleeping  sickness , 589 

spinal  meningitis 507 

round  worms  595 

tape  worms 604 

tuberculous  meningitis 507 

whooping  cough  492 

yellow  atrophy 107 

Copremia,  in  chlorosis 232 

Cor  bovinum   165 

Corneal  ulcers,  in  fifth  nerve  lesion  438 

Corns,  lingual   23 

Coronary  arteries,  disease  of 149 

spasm   of    150 

Corpulence   290 

Cortex,  visual,  lesion  of. 435 

Corrigan's  disease   470 

Coryza    183,  184 

rubella 561 

syphilitic   baby    526 

Costiveness    60 

Cough,  in  aneurysm  of  aorta 175 

brassy,  laryngeal  diphtheria  495 

cardiac  diseases 135 

gastritis    42 

hay  fever 187 

influenza    489 

malaria 583 

mouth  breathing  191 

plague 529 

pulmonary  diseases.  .201,  465,  489,  501 

subphrenic  peritonitis   131 

'  whooping  cough   492 

Coup  de  soleil 316 

Cow  pox  546 

Cramps,  see  colic  and  pain 

Cranial  nerves,  diseases  of 433 

Cretinism    , 300 

Crises,  in  hysteria 394 

Croup    202,  203 

membranous    202,  495 

Croupous  pneumonia   500 

Cry,  epileptic 410 


Cnrptogenic    erysipelas    515 

Curschmann's  spirals,  in  bronchial 

asthma   211 

Cutaneous  Leishmaniasis    587 

Cyanosis,  adult,  cardiac 

disease  145  et  seq. 

chronic  nephritis    256 

polycythemia    239 

pulmonary  diseases 206  et  seq. 

thyroiditis   295 

child- 
cardiac  disease  138,  168 

pertussis    492 

Cycloplegia   437 

Cystic   kidney    263 

Cystitis,  from  blood  flukes 602 

Cyst,  hydatid,  of  liver 113 

Cysts,    on    joints 278 

pancreatic    125 

Dandy   fever    570 

Day-blindness    434 

Deafness,  in   441 

hysteria    394 

meningitis   508 

mouth   breathing    191 

mumps   .564 

rhinitis   .183 

typhoid 480 

Death,  sudden,  in — 

abscess   of   brain    389 

angioneurotic  edema  316 

apoplexy    375 

cardiac  diseases 139  et  seq. 

pancreatic  hemorrhage  123 

purpura  hemorrhagica 310 

rupture    mesenteric   artery 177 

status  lymphaticus 313 

Dengue    570 

Dercum's  disease 290,  291 

Desert  sickness 320 

Dew  itch  598 

Diabetes  mellitus  279 

bronzed    110 

insipidus    283 

in  tumors  of  fourth  ventricle 389 

Diaceturia,  in  typhoid 480 

Diaphragm  phenomena   of   Broad- 
bent 138 

Debility,  in  constipation 61 

Defecation,  difficult,  in — 

constipation    61 

enteralgia    55 

hemorrhoids    63,  179 

intestinal   anesthesia    55 

mucous  colitis   56 

proctitis   101 

prostatitis    268 

vagotonia    445 

Defective  children — 
amaurotic   idiocy    382 


INDEX 


615 


cretinism   301 

cerebral  paralyses   382  et  seq. 

syphilis 525 

Degeneration  of  heart,  fatty 144 

Deglutition,  difficult,  in  glossitis..  22 

parotitis   562 

tetanus  532 

syphilitic  laryngitis    524 

(See  dysphagia) 

Delhi   boil    587 

Delirium  acutuni    379 

cordis 156 

Delirium  in — 

acute  articular  rheumatism 518 

Addison's  disease  307 

alcoholism  323  et  seq. 

apoplexy    375 

cerebral  leptomeningitis  341 

desert  sickness 320 

ergotism 335 

fevers,  q.  v. 

gout    272 

heat  injuries   316,  318 

hemolytic  anemia   236 

hemorrhagic  jaundice  528 

lead  poisoning 329 

liver,  cirrhosis   109 

yellow  atrophy   107 

malaria 582 

myelitis    349 

pancreatitis  124 

pericarditis    135 

snow  blindness 319 

spinal  meningitis 508 

strangulation    75 

Delirium   tremens    325 

Dementia,  in  acromegaly 304 

alcoholism  325 

cocainism    v328 

ergotism    335 

tabo-paralysis     349 

myxedema 302 

paralysis    347 

progressive  chorea  416 

senility     379 

Diarrhea 54 

acute    79,  90 

alba  89 

chylosa  89 

nervous    55 

spurious  61 

tubular   56 

Diarrhea,  in  actinomycosis 535 

Addison's  disease  307 

amyloid  liver  114 

anaphylaxis 321 

anthrax    538 

autointoxication    65 

cholangitis    115 

colitis   94 


constipation    61 

diabetes 281 

dysentery,  tropical   . . .'. 569 

endocarditis    160 

enteritis,  adults 90-100 

enteritis,  children   79-89 

exophthalmic  goiter  298 

febrile  icterus    566 

fluke  disease    600 

food   poisoning    336,   ZZJ 

gastric  cancer 48 

gastritis    38,  42 

gout 272 

hemolytic  anemia  235 

hemorrhagic  jaundice  528 

hydronephrosis    260 

infantile  paralysis 511 

influenza    489 

jaundice 104 

lamblia  infection 588 

malaria    582 

obstruction 71,  77 

pancreatitis     125 

paratyphoid    486 

pellagra 334 

psorospermiasis   589 

purpura    309 

relapsing  fever   520 

scorbutus    289 

stomatitis    20 

tabes  dorsalis 346 

trichinosis    597 

typhoid   484 

typhus .487 

(See   dj'^sentery) 

Diazo-reaction,  typhoid 481 

Diet,  in  tuberculosis 464 

Digestive   system,   general   discus- 
sion     13 

Dilatation  of — 

bronchi 209 

colon,  acute  paralytic 71 

idiopathic   congenital    •. . . .  71 

in  constipation 61 

esophagus   32 

heart 145 

in  diphtheria    , 496 

intestine    71,  72 

Diplopia    438 

in   tabes   dorsalis 346 

Dipsomania    324 

Diphtheria    494 

Dirt  eaters 598 

Discomfort  (see  pain) 

Disseminated  myelitis   349 

Distoma  hematobium   601 

hepaticum   600 

pulmonale    601 

siense    602 

Diver's  paralysis 362 


616 


INDBX 


Diverticulum  of  esophagus 32 

Dizziness,  see  vertigo 

Dog  tape  worm  605 

Dracontiasis 593 

Drooling,  bulbar  palsy 366 

Dropsy,  see  edema 

Drowsiness,   after   meals,   in   fatty 

heart    144 

hypochlorhydria   Z3 

nephritis  255 

Dry  catarrh  of  bronchi 207 

Dry  mouth  _^ 26 

in  diabetes  insipidus 283 

diabetes  mellitus    280 

fevers,  q.  v. 

food  poisoning   ZZ7 

glossitis   22 

stomatitis  16  et  seq. 

Drunkard's  dyspepsia 41 

Dubinins  chorea 421 

Duchenne-Aran  atrophy  ^ .  365 

Duchenne's  subacute  ascending 

paralysis    365 

Duodenitis    90 

Duodeno-cholangitis   115 

Dum-dum  fever   586 

Dwarfism    305 

Dysacusis    441 

Dysbasia  lordica  progressiva 451 

Dysentery    101 

acute    94 

amebic   589 

bacillary   569 

tropical    569 

in  variola    543 

(See  diarrhea) 

Dyspepsia  34,  38,  41 

Dyspeptic  diarrhea  of  children ....  79 

Dysphagia,  in  bulbar  palsy 366 

diseases  of  esophagus 30 

food  poisoning  ZZ7 

hydrophobia  531 

lenticular    disease    387 

pericarditis     135 

quinsy   190 

tuberculous  laryngitis 471 

Dysphonia,  in  hydrophobia 531 

Dyspnea,  in  blood  diseases233,  235,  240 

cardiac  diseases 135-176 

exophthalmic  goiter    299 

gastric  dilatation    50 

gout    272 

heat  apoplexy   317 

hydatid  cyst  of  liver 113 

hydrophobia  531 

interstitial  nephritis 255 

laryngeal  spasm  444 

malaria    583 

pancreatic  disease    124,  125 

pulmonary  diseases   206-223 


scarlet    fever 551 

subphrenic  peritonitis  131 

thyroiditis    295 

Dystrophia    adiposogenitalis  304 

Dystrophies,  muscular  450 

Ear,  in  scarlet  fever 554,  556 

Ecchymoses,  plague   529 

Echinococcus  of   liver 113 

Echokinesis,  general   tic 420 

Eclampsia  infantilis    416 

Edema,  angioneurotic 316 

false,  in  myxedema  302 

in  neuritis  430 

general,  in  anthrax   538 

beri-beri 566 

edema,,  fluke  disease  602 

gastric  cancer    48 

heart  diseases 138-176 

hookworm  disease  598 

kidney  diseases 241-255 

leukemia    241 

liver,  diseases  of   105-114 

pancreatic  cancer   126 

phthisis    470 

purpura    310 

scarlet  fever 555 

scurvy    289 

tetany  303 

tricuspid  stenosis   168 

Edema  of  face,  in — 

aneurysm  of  aorta  176 

anthrax 538 

erysipelas    516 

variola    541 

brain  273 

fingers  or  toes,  Raynaud's  disease. 316 

glottis  200 

lung   217,  157 

peritoneum   128 

Effusion,  in  pleuro-pneumonia 505 

Egyptian  chlorosis    598 

Electric  chorea  421 

Elephantiasis   596 

Emaciation  or  wasting  in — 

actinomycosis  535 

amebic  dysentery   590 

aortic  aneurysm   176 

beri-beri  566 

brain  tumor   388 

cancers,    q.   v. 

cholangitis    116 

cocainism 328 

diabetes  mellitus  280 

entero-colitis   of  children    87 

esophagus,  disease  of  31 

exophthalmic  goiter 298 

febrile  icterus    567 

fluke  disease  600 

congenital  dilatation,  of  colon 72 

leukemia    240 


INDEX 


617 


liver,  cirrhosis  of  108 

malaria 582 

morphinism 326 

pancreatitis  125 

peritonitis    133 

pineal  disease 308 

rachitis    286 

tropical   dysentery    570 

tuberculosis   459  et  seq. 

typhoid 480 

(See  cachexia) 

Embolism,  of  brain 376 

kidney    263 

spleen  312 

Embryocardia   155 

Emotionalism,  excessive,  in — 

basilar  leptomeningitis   341 

cerebral  hemorrhage  Z76 

hysteria    394 

lateral  sclerosis  369 

neurasthenia  399 

progressive  chorea  416 

Emphysema   219 

in  bronchial  asthma  212 

chronic  bronchitis 207 

whooping  cough  492 

Emprosthotonos,   in   tetanus 533 

Empyema   224 

in  measles  558 

pleuro-pneumonia  505 

tuberculosis 468 

Encephalopathy  saturnina 329 

Endarteritis    172 

syphilis     523 

Endocarditis   158 

in  acute  articular  rheumatisixi  ....518 

erysipelas 516 

pneumonia    505 

Endocardium,  diseases  of 158 

English   cholera    : 93 

Enteralgia    55,  59 

Enteritis,  adults   90 

children   79 

membranacea   56 

remitting,  sprue    567 

(See  diarrhea  and  dysentery) 

Entero-colitis,  adults  90.  100 

children    84,  87 

Enteroplegia    71 

Enterospasm    55 

Enuresis    265 

in  nocturnal  epilepsy   410 

Eosinophilifi,  in  amebic  dysentery. 591 

autointoxication    66 

bronchial  asthma    211 

gastritis   43 

hookworm  disease   599 

scarlet  fever  552 

worms 594  et  seq. 


Epidemic  cerebro-spinal 

meningitis 506 

roseola  560 

stomatitis 534 

(See  fevers) 
Epigastrium,  enlarged  in  left  area,  in 

pancreatic  cyst    125 

pulsation  in,  hypertrophy  of  right 

ventricle    147 

pancreatic  cancer   126 

(See  pain,  epigastrium) 

Epilepsy  408 

Jacksonian  408,  411 

in   fluke   disease    601 

myoclonic    . .  .^. 408 

nocturnal  408 

psychic    408,  411 

running    408 

symptomatic  408 

syphilitic    525 

Epilepsy  or  epileptoid  attacks,  in 
or  after — 

cerebral  hemorrhage  376 

cerebral  meningitis 339 

chronic  entero-colitis  of  children..  87 

fatty  heart   144 

heat  inj  uries    318 

hemiplegia  of  children  384 

hysteria    394' 

influenza    490 

paralytic  dementia  348 

typhoid    480 

Epileptic  character   ..413 

equivalent   408 

Epiphysis  (see  pineal  body) 308 

Epistaxis  180 

in  cirrhosis  of  liver 108 

dilatation  of  heart 145 

diphtheria    495 

febrile  icterus    567 

hypertrophy    of    heart 147 

malaria   582  et  seq. 

purpura    310 

scarlet   fever    551 

scorbutus 289 

typhoid    479 

whooping  cough  492 

Equinia    536 

Erb's  type,  muscular  atrophy 366 

Ergotism    335 

Eructations 35 

in  aerophagia f.x. 35 

cirrhosis  of  liver 108 

gastritis    38,  42 

gastro-enteroptosis    69 

hyperchlorhydria    ZZ 

Eruption,  or  rash,  in — 

actinomycosis    535 

acute  articular  rheumatism 518 

anthrax 537 


618 


INDEX 


beri-beri    566 

chickenpox   548 

cholera    576 

dengue    571 

diabetes    mellitus     280 

diphtheria   496 

erysipelas    515 

foot  and  mouth   disease 534 

gout    272 

hemorrhagic  jaundice 528 

influenza    490 

measles    557 

miliary  fever   568 

nephritis    256 

pellagra    334 

purpura    309 

rocky  mountain  fever 587 

rubella 561 

scarlet   fever    550 

syphilis  523,  526 

typhoid    479 

typhus    ■ 487 

vaccinia    547 

variola    541 

yaws 568 

Erysipelas    i  515 

after  vaccination    547 

Erythrocytes,  abnormal,  in 

»    anemias    229  et   seq. 

Esophagus,  diseases  of 29-33 

Etiology — 

alcohol,  in  amblyopia 433 

arteriosclerosis    172 

aortitis   1 59 

brain  diseases.339,  348,  383.  373,  409 

cardiac  diseases   153,161,162 

cystitis   266 

digestive  system  diseases.  .16-125 

erysipelas    515 

heat  injuries   317,  318 

nephritis  249,  254 

neuritis    429,  435 

respiratory  tract,  diseases 

of    198,  201,  217,  223 

senility,   premature    379 

spinal  diseases 341,  342,  351 

birth  accidents,  in — 

cerebral   hemorrhage    374 

epilepsy 409 

paralysis    382 

bony  lesions,  many  diseases 
cryptogenic  infectious  foci,  in — 

acute  rheumatism 517 

arthritides  276 

chronic  gastritis   41 

exophthalmic  goitre    298 

muscular  rheumatism  274 

dietetic  errors,  in — 

arteriosclerosis    172 

autointoxication    64 


beri-beri    566 

cardiac  diseases  153,  162 

constipation    60 

diabetes  mellitus    279 

enteritis    79,  90 

gastric  diseases   35,  38 

gout  271 

hepatic  diseases.  .105,  115,  118,  578 

kidney  diseases 254  et  seq. 

obesity   290 

pellagra 289 

simple  fever  320 

stomatitis    16  et   seq. 

rachitis    286 

(See  malnutrition) 

drugs,  in — 

alcoholism    323 

arteriosclerosis    172 

cardiac  diseases 144,   162,   170 

constipation 61 

enteritis  90,  92,  100 

fecal  impaction   75 

gastric  diseases 35  et  seq. 

heat  exhaustion    318 

intussusception    76 

kidney  diseases 249,  251,  257 

malaria 583 

obstruction   74 

poisoning  322  et  seq. 

proctitis  101 

ptyalism    26 

serums,   in  anaphylaxis 321 

spinal  diseases  352 

stomatitis    18,  19 

pancreatitis    124 

hereditary  or  congenital  states,  in — 

alcoholism   323 

amaurotic   idiocy    382 

anemia    230 

arteriosclerosis    172 

cardiac  neuroses  153 

cerebral  diplegia 385 

chlorosis  232 

collapse  of  lung 2t8 

cretinism   301 

dilatation  of  bowel 71 

emphysema    219 

chronic  endocarditis   161 

epilepsy   409 

familial   sclerosis    .^ 344 

gastroenteroptosis  ' 68 

Gaucher's   disease    238 

goiter   296 

gout   270 

hemophilia    311 

hydrocephalus   380 

hysteria    391 

lateral  sclerosis  368 

migraine    405 

myotonia  congenita 450 


INDEX 


619 


nephritis    254 

neurasthenia    398 

paralysis  periodic  433 

paralysis  children's    382 

premature  senility   379 

progressive   chorea    415 

obesity   . . , 291 

rachitis    286 

spinal  ataxia    370 

syringomyelia    360 

syphilis    525 

valvular  heart  lesions 168 

nervous  control  disturbed,  in — 

bladder  neuroses .264 

bronchial  asthma   210 

cardiac  neuroses 153 

cerebral  anemia    372 

chorea 414 

constipation    60 

convulsions  in  children 416 

costogenic  anemia   231 

croup   204 

diarrhea    55 

enuresis    265 

esophagismus     31 

exophthalmic  goiter    298 

gastric  neuroses   35 

hay  fever 186 

intestinal  neuroses    54,  68 

purpura,  factitious   310 

tic  419,  420 

xerostomia    26 

senility,  in — 

arteriosclerosis    172 

arthritides    276 

emphysema    219 

nephritis    254 

neuritis    429 

pulmonary    gangrene    ........221 

purpura    309 

tremor    452 

syphilis,  in  cardiac,  digestive,  ner- 
vous, vascular,  skin  and  endo- 
crine,   diseases 522    et    seq. 

syphilis,    parental,    in — 

abortions     525 

anemia    238 

cretinism    301 

deaths  of  small  babies 525 

icterus  neonatorum   105 

mental  defectives 525,  526 

otorrhea    526 

paralysis    383 

rachitis  286 

tobacco,  in — 

amblyopia   433 

cardiac   neuroses    153 

digestive  diseases.l6,  20,  30,  41  195 

dilatation  of  heart 146 

(See  internal  secretions) 


Exaltation,  early  paralytic 

dementia    .348 

Exophthalmos,  in  goiter. ... 298 

Extra-systole 156 

Extravasations,  in  jaundice 104 

Eye  balls,  proturberant,  in 

exophthalmic  goiter   298 

Eyes,  dull,  in  hookworm  disease.. 598 
Eczema,  in  diabetes  mellitus  280 

Face,  deformed,  in  acromegaly 304 

flushed,  dusky,  in  typhus 486 

leonine,  in  leprosy 475 

mask-like,  in  paralysis  agitans..422 
pinched,    blue,    cold,    moist,    in 

cholera 576 

pinched,  bluish,  in  malarial 

chill ..582  et  seq. 

swelling  around  jaw,  in 

actinomycosis    535 

mumps   562 

swollen,  red,  burning,  in 

erysipelas   516 

(See  atrophy  and  pain) 
Facial  grimaces,  in  acute  chorea.. 415 

Facial  nerve,  lesions  of 438 

Facial  neuralgia   426 

Failure  of  cardiac  compensation.  .145 

Falling  disease   408 

False  measles   560 

Family    paralysis     453 

Fatigue,  facile,  in  neurasthenia.399,  401 

nephritis    255 

Fatty  heart 144 

Fatty  livef   114 

Fatty  stools,  see  feces 

Farcy   536 

Farcy-buds    537 

Febris  recurring 520 

Fecal  impaction   75 

in   croupous  enteritis... 92 

Feces  in  diagnosis . . . .  • 54 

Feces  or  stools,  musty;  in  enteritis 

of  children   '. 83 

bloody,   in   anthrax 538 

colitis    94,   100 

enteritis   80,  84,  91 

obstruction    7Z,  77 

purpura   309  et  seq. 

proctitis     101 

typhoid    479,  481 

contain,  fecal  concretions 78 

gallstones    119 

pancreatic    calculi 127 

contain   fat,   in   jaundice 104 

pancreatic  diseases 125,  126 

contain  undigested  muscle  fibers, 

pancreatic  disease    125 

contain  worms  or  their 
eggs   594  et  seq. 


620 


INDEX 


dry,  in  constipation   60,  61 

proctitis     101 

enormous,    in    congenital 

dilatation  71 

flat,  in  chronic  obstruction  77 

greenish,  "spinach,"  enteritis  of 

children    84 

mucous,   chronic  entero-colitis.  .100 

acute  enteritis  91 

pale  or  clayey,  in — 

aortic  aneurysm    176 

icterus  neonatorum   104 

liver  diseases 103  et  seq. 

lumpy,  foul,  chronic  entero- 
colitis of  children 87 

pancreatic  diseases 125  et  seq. 

"pea  soup,"  oflFensive  odor,  in 

typhoid    479 

"rice  water,"  in  cholera 575 

cholera  morbus  93 

yeasty,  copius,  in  sprue 567 

pipe   stem,   in   chronic 

obstruction   77 

tarry,  in  cirrhosis  of  liver 108 

duodenal  ulcer    45 

hemorrhage  in  typhoid 481 

yellow  atrophy   107 

thin,  frothy,  foul  in  enteritis 

of  children  82  et  seq. 

variable  color,  in  hypertrophic 

cirrhosis     110 

voided  in  epilepsy   410 

,  spinal  meningitis   341 

Feet,  overgrown,  in 

syringomyelia 361 

Feidler's  disease  566 

Fermental  enteritis  of  children    . .   81 
Fetor,  in  malignant  scarlet  fever.. 552 

Fetor  oris  21 

Fever,  in  acute  articular 

rheumatism    517 

alcoholism 323  et  seq. 

apoplexy   375 

appendicitis    96 

brain  abscess   390 

chorea  415 

delirium  acutum   379 

endocarditis    158,  160 

ergotism    ^ . . .  335 

enteritis    80,  84 

gastro-intestinal    diseases. . . .  16-130 

gout 271 

heat  injuries  317 

hemiplegia  of  children  384 

Hanot's  disease 110 

hepatic  abscess   Ill 

Hodgkins'  disease    244 

infectious  and  parasitic 

diseases  456  et  seq. 

kidney  diseases   .' 249-260 


Landry's  disease    364 

leukemia   240,  241 

lung  diseases  212,  224,  500 

malaria    581    et    seq. 

meningitis    339,  341 

myelitis    357 

pancreatitis    124 

pericarditis   135 

pneumonia    500 

poisoning,  food    336,  337 

purpura    310 

rhinitis   183 

rachitis     286 

simple  continued    320 

tetanus  532 

tetany    303 

thyroiditis  295 

tonsillitis     188 

typhus    486 

(See   Temperature,   subnormal) 

Fibroid   heart    141 

Filariasis  595 

Fingers,  amputated,  in  leprosy 475 

clubbed,  in  mitral  lesions  163 

pale,  numb,  in  Raynaud's 

disease   315 

swollen,  in  gout  272 

(See  Ergotism) 

Fish  poisoning    336 

Fish  tapeworm    604 

Fistulas,    proctitis    101 

Fits,    hysterical    394 

Flagellata 588 

Flashes,  heat,  exophthalmic- 
goiter    299 

Flatulence,  in — 

acute  dilatation,    71 

acute  enteritis 80,  91 

cancer  of  liver   112 

chronic  entero-colitis  of 

children    87 

cirrhosis  of  liver    109  et  seq. 

constipation    61 

gastric  dilatation    50 

gout 271 

hyperemia  of  liver 105 

hyperchlorhydria    33 

jaundice   104 

peritonitis    130 

Flies,  larvae,  in  myiasis 592 

Floating  kidney   261 

Flukes    600 

Focal  symptoms,  brain  tumor   ,..388 
Follicular  enteritis  of  children  ....  84 

Food  poisoning 332 

Foreign  bodies,  in  obstruction   . . .  72 

Foot  and  Mouth  disease  534 

Foot,  deforming  nodules  and 

ulcers,  in  Madura  foot   567 

Frambesia  tropica 568 


INDEX 


621 


Friedrich's  sign    138 

Frigidity,  in  hysteria 394 

Fremitus,  in  pericarditis   136 

French  measles    560 

Frolich's  type   304 

Frontal  neuralgia  426 

Fungus   foot    567 

Gait,  ataxic  in — 

chronic   alcoholism    325 

ergotism    335 

hemolytic  anemia 236 

tabes   dorsalis    346 

monkey,  or  dromedary,  in 

tortipelvis    451 

scissors,  in — 

lateral  sclerosis  369 

cerebral  diplegia 386 

spastic,  in  lateral  sclerosis 369 

steppage,  in  diabetes  mellitus  .  .  .280 
trotting,  in  paralysis  agitans.  .  .  .422 

wooden,  in  tetanus 532 

Galactotoxismus  336 

Gall  bladder,  diseases  of 115 

Gall  stones  118 

Gall  stones,  in  croupous  enteritis  .  92 

obstruction   72 

Gangosa    569 

Gangrene,  in — 

amebic  dysentery   591 

chickenpox    549 

cholera  576 

ergotism    335 

pancreatitis     124 

pulmonary  diseases    213,  221 

due  to  trichonomas  588 

Raynaud's  disease   315 

senility    173 

spinal  meningitis   508 

stomatitis    20 

strangulation    75 

syringomyelia    360 

typhus    487 

vaccination   547 

variola    543 

Gas  in  abdomen  

(See  flatulence) 

Gastralgia   34 

in  gout   272 

Gastrectasis    49 

Gastric  crises,  in  tabes  dorsalis. .  .346 
disturbances,  cirrhosis  of  liver..  108 

fever    38 

symptoms,  in  jaundice    104 

ulcer,  in  chlorosis   '..232 

Gastritis,  in — 

chronic  bronchitis    207 

desert  sickness    320 

duodenitis   90 

pancreatic  cancer  126 

pneumonia    505 


Gastro-enteroptosis   68 

Gastro-intestinal  catarrh,  in  yellow 

atrophy    107 

Gastroxynis    34 

Gaucher's  disease 238 

Genital  organs,  tuberculosis  of... 474 

General  paretic  dementia   347 

General  tic   420 

Geographical  tongue 22 

Giantism    304 

Giddiness,  acute  food  poisoning. .  .337 

caisson  disease 363 

(See  vertigo) 

Gingivitis,  diabetes  mellitus  280 

ulcerosa   > 18 

Girdle  sensation,  tabes  dorsalis. .  .346 

Glanders    536 

Glands,  enlarged  (See  lymph  nodes) 

Glandular   fever    564 

Glenard's  disease   68 

Gliosis  of  horn  of  Ammon,  in 

epilepsy   408 

Globus  hystericus    443 

Glossitis 21 

Glosso-pharyngeal  nerves,  lesions. 443 

Glottis,  edema  of 200 

spasm  of  203 

Glycosuria,  in — 

autointoxication    66 

bronzed   diabetes    110 

diabetes  mellitus    281 

pancreatic    diseases    125,  126 

renal  diseases 246 

whooping   cough    493 

Gnashing  of  teeth  in  sleep,  from 

worms   . . . : 594  et  seq. 

Goiter,  exophthalmic    297 

simple 296 

in   chlorosis    232 

Gonads,  internal  secretions  of   ...308' 

Goundoni  568 

Gout   270 

Gouty  kidney 253 

Grand  mal    408 

Gravel 258    , 

Grave's  disease   297 

"Green  sickness"   232 

Green  tumor 239 

Grimaces,  tic  419 

Grinding  of  teeth,  in  children, 

chronic  entero-colitis   87 

Grip    489 

Gripes    59 

Ground  itch   598 

Growth  stunted,  in  hookworm 

disease    598 

Guinea  worm  disease   593 

Gumma,  resembling  brain  tumor.. 525 
Gummata    523 


622 


INDEX 


Gums,  bleeding  in,  scorbutus 289 

blue-black  line,  in  lead 

poisoning    328 

hemorrhagic,  in  anthrax   538 

ulcerated,  in  stomatitis    18 

Habit  chorea  419 

spasm  419 

Hair,  coarse,  or  whitened, 

neuritis    430 

Hallucinations,  in 

alcoholism 323  et  seq. 

(See  delirium) 
Hands,  over-grown,  in 

syringomyelia    ^ 360 

acromegaly     304 

tremulous,  chronic  alcoholism.  .325 

Hanot's   disease    110 

Harrison's  groves,   rachitis    287 

Hawking,  in  chronic  rhinitis 184 

Hay  fever 186 

Hay  garth's  nodosities 278 

Headache,  in — 

aortic  lesions   165,  167 

arsenicism     331 

arteriosclerosis 173 

autointoxication    65 

brain   abscess    390 

brain   congestion    Z73 

brain  tumor   388 

caisson  disease   363 

cardiac  dilatation  145 

hypertrophy   147 

cephalodynia    274 

chlorosis    233 

diabetes  insipidus 283 

ergotism    335 

enteritis   91 

fevers,  q.  v. 

gastric   neuroses    33,34 

gastritis  42 

gout    272 

hay  fever 187 

heat   injuries    317 

kidney  diseases    250,  255 

lead  poisoning   328,  329 

liver  diseases   105,  107 

meningitis    341,  339,  469,  507 

mouth   breathing    191 

nephritis    250,  252,  255 

neurasthenia     400 

plague    529 

polycythemia   239 

proctitis  101 

purpura    310 

rhinitis   183 

sleeping  sickness   589 

tetanus   532 

Headache  medicines   331 

Headache,  preceding  cerebral 

hemorrhage    375 


'   unilateral,  in  migraine   405 

Head,  enlarged,  in  hydrocephalus. 381 

rachitis 287 

retracted,  enteritis  of  children..  83 

spinal  meningitis 341,  507 

Heart,  abscess  of 141 

dilatated,  in  diphtheria    145 

dilatated,  in  whooping  cough., 492 

fatty 144 

injuries    148 

misplacements 148 

neuralgia   ISO 

neoplasms    149 

neuroses .153 

small,  in  chlorosis   232 

syphilitic    523,  524 

weak,  Addison's  disease 307 

Heart-block    156 

Heat  apoplexy    317 

cramps   317 

exhaustion    318 

flashes,  in  acute  gastritis 38 

in   autointoxication    65 

Heat-sense,  lost  in  syringomyelia. 360 

Heat-stroke  316,  317 

Heberden's  modes  278 

Hematemesis,  differentiated  from 

hemoptysis   216 

Hematemesis,  in — 

aneurysm  of  hepatic  artery 177 

aneurysm  of  splenic  artery 177 

cancer  of  esophagus  30 

stomach     49 

cirrhosis  of  liver 108 

peptic  ulcer    44 

peliosis  rheumatica   310 

stomatitis 18 

tricuspid  regurgitation 167 

yellow  iever    573 

Hematomelia   355 

Hematorrachis    355 

Hematuria    245 

in  blood  fluke  disease 602 

endocarditis     159,  160 

febrile  icterus    567 

hemorrhagic  jaundice 528 

hepatic  cancer 112 

prostatitis    268 

purpura 310 

relapsing  fever   521 

scarlet  fever 551 

Hemeralopia    434 

Hemianopsia    435 

Hemicrania    404 

Hemiplegia,  cerebral,  of  children.  .383 
Hemiplegia,  double,  in  children. .  .385 
Hemoglobin  diminished, 

anemias,   229  et  seq. 

Hemoglobinuria,  in  urinary 
diseases    245 


INDBX 


623 


malaria    583 

Raynaud's  disease    316 

Hemolytic  anemia  235 

Hemopericardium    139 

Hemophilia    311 

Hemoptysis  215,  216 

in  aortic  aneurysm  176,  215 

bronchiectasis    ^ 209 

endocarditis    159 

fluke  disease   601,  465 

mitral  lesions   163,  164 

parasitic  diseases   215 

tuberculosis    465 

Hemorrhages, 

cerebellar    376 

cerebral    374 

in  syphilis  525 

in  hypertrophy  of  heart 147 

gastric    (see   hematemesis) 
intestinal,  in — 

amebic  dysentery 590 

pancreatic    cyst    125 

typhoid   480,  484 

meningeal   374 

pancreatic   123 

pulmonary  (see  hemoptysis) 
nasal  (see  epistaxis) 
subcutaneous  and  submucous,  in 

aplastic  anemia 244 

dengue   571 

foot  and  mouth  disease   534 

Gaucher's  disease 238 

hemophilia    311 

hemolytic  anemia 236 

Hodgkins'  disease   244 

icterus  106,  528 

chronic  splenomedullary 

leukemia  .' 240  et  seq. 

purpura    309 

(See  also  hemorrhagic) 

rectal    78 

retinal    434 

spinal    355 

urinary,  see  hematuria   

uterine,  see  metrorrhagia   

ventricular    376 

Hemorrhagic  or  malignant 

diphtheria    496 

malaria     583 

measles    557 

nephritis    249 

small  pox 542 

variola    542 

whooping  cough 492 

yellow  atrophy   107 

yellow  fever 574 

Hemorrhoids   178 

in  cirrhosis  of  liver 108 

constipation 61,  63 

proctitis  101 


Henoch's  chorea 421 

purpura 310 

Hepatic  abscess 112,  590 

Hepatic  distomiasis 602 

Hepatitis   108 

acute    purulent    Ill 

interstitial 108 

pneumococcic 505 

syphilitic 523 

Hereditary  spinal  ataxia  370 

Hernia   7Z 

strangulated   75 

after  whooping  cough 492 

Herpes  labialis   24 

Herpes  facialis   24 

in  acute  rhinitis   183 

meningitis    .v342,  508 

Herpes  zoster,  in  diabetes  mellitus.280 
Hiccough,  obstinate,  in — 

aortic  aneurysm 176 

pancreatitis  124 

perforation,  typhoid    480 

pericarditis   135 

peritonitis   130 

Hirschsprtmg's  disease 71 

Hoarseness,  in  syphilitic  . 

laryngitis     524 

Hodgkins*  disease   243 

after  vaccination   547 

Hookworm  disease   598 

Hopefulness,  in  tuberculosis   467 

Hornpox   543 

Hunger,  in   diabetes   mellitus 279 

Hunger  pain,  in  duodenal  ulcer  ...  45 
Hunger,  variations  in,  see  Neuroses 

of   stomach    ZZ   et   seq. 

(See  appetite) 

Hutchinson  teeth  526 

Hutchinson's  triad  526 

Hydatid  cysts,  in  lungs 222 

liver 113 

Hydatid  disease   605 

Hydrocephalus    380 

in   tuberculosis    469 

Hydrochloric  acid, 

absent  in   chronic  gastritis    ....  43 

gastric  cancer  48  ' 

decreased  in — 

gastritis    39,  43 

gastric  cancer   48 

late  gastric  dilation  51 

hemolytic  anemia 235 

increased  in — 

gastric  neuroses   Z3 

peptic  ulcer    45 

early  gastric  dilatation    51 

Hydrothorax    225 

Hydronephrosis    260 

Hydropericardium   139 

Hydroperitoneum    128 


624 


INDEX 


Hydrophobia   530 

Hyperacidity   of  gastric   juice    . . .  2)Z 

Hyperacusis    441 

in  Bells'  palsy  -.  .440 

Hyperchlorhydria    33 

Hyperchromaffinopathy   306 

Hypercythemia,   see   polycythemia 

Hyperemia  of  brain 372 

kidney    247 

liver 105 

lungs    215 

in  early  pneumonia  501 

pharynx  195 

spleen     312 

Hyperesthesia,  gastric   34 

in  meningitis 342,  508 

hysteria    394 

HypersensitivenesS,   (see  pain) 
Hyperesthesia,  in  hydrophobia  ...531 

Hyperexia,  heat  injuries   318 

Hyperglycemia,  in  diabetes 

mellitus    280 

Hsrperhypophysism   304 

Hyperkinesis,  of  stomach  34 

Hypemephrinemia    306 

Hypernephroma    262,  306 

Hyperorexia    34 

Hyperosmia    433 

Hyperpituitarism    304 

Hyperpnea,  spinal  meningitis 507 

Hypersecretion  of  gastric  juice 33 

Hypersecretion  of  saliva 26 

Hypersensitiveness, 

scattered  areas  of  body  in  tetany .303 
Hypertension,  in  arteriosclerosis.  .173 

Hyperthyroidism 297 

Hypertrophic   cirrhosis    110 

Hypertrophy  of  auricles  147 

heart 149 

muscles  after  paralysis 512 

prostate   268 

right  ventricle  147 

tonsils 190 

Hypochlorhydria 33 

Hypochlorhydria,   in   hemolytic 

anemia    235 

Hypochondria,  in  stricture  of 

esophagus   31 

HsTJOgastric  neuralgia 55 

Hypoglossus,  lesions  of 446 

Hypohypophysism  304 

Hypophysis  adiposity 305 

Hsrpopituitarism  306 

Hyposecretion,   of    saliva 26 

Hypothermia,  heat  exhaustion 318 

Hysteria  391 

confused  with  hydrophobia 531 

confused  with  multiple  sclerosis. 344 

in    renal    neuroses 258 

Icthyosis  lingualis  23 


Icthyotoxismus  336 

Icterus  103 

febrile 566 

gravis   106 

hemorrhagic  528 

hereditary   104 

neonatorum  104 

in  tricuspid  regurgitation 167 

Idiocy,  amaurotic  382 

Ignis  sacer  515 

Ileitis 90 

Ileus   72 

Iliac  abscess 95 

Impacted   gall-stones    119 

Impaction,  fecal  75 

Impetigo,  after  vaccination 547 

Impotence,  in  diabetes  mellitus. .  .280 

meningomyelitis   359 

tabes  dorsalis 346 

Incontinence  of  urine,  in 

enuresis    265 

epilepsy 265,  410 

tabes  dorsalis 346 

Indicanuria,  in  appendicitis 96 

autointoxication 66 

brain   abscess    390 

cancers,  q.  v. 

costogenic  anemia  230 

empyema    225 

hemolytic  anemia  236 

kidney  diseases  246 

gastro-enteroptosis 69 

Indigestion,  nervous,  of  children..   79 

Indoxyl,  increased  in  cholera 577 

Infantile  anemia  238 

Infantile  convulsions   416 

Infantile  paralysis   510 

Infarction,  of  brain 376 

Infectious  diseases.  Part  IX 454 

general  prophylaxis 457 

general  treatment 455 

Infiltration  of  heart,  fatty 144 

Inflammatory  diarrhea  84 

Inflammation  of  bowels 90 

Inflammatory  rheumatism 517 

Influenza   489 

Injuries  of  heart 148 

Insanity,   acute    confusional,   after 

typhoid    480 

influenza  490 

scarlet  fever 556 

mercurialism    330 

Insolation 316 

Insomnia,  in  aortic  stenosis 167 

arteriosclerosis    173 

autointoxication    65 

costogenic  anemia  231 

fevers,  q.  v 

heat  injuries  317 

leukemia    242 


INDEX 


625 


liver  diseases  107 

morphinism    326 

nephritis    255 

neurasthenia    399,  400 

Internal  secretions,  see 

acromegaly     304 

Addison's    disease    306 

cretinism   300 

diabetes  insipidus 283 

diabetes  mellitus 279 

ductless  glands,  discussion   294 

exophthalmic  goiter    297 

gonads   308 

hypophysis  adiposity    .  .^ 305 

multiglandular  diseases  * 308 

myxedema     300 

pineal  body    308 

pituitary  body   304 

tetany    303 

Intermittent  fever   581 

Interstitial  hepatitis    108 

Intestines,  diseases  of 54  et  seq. 

Intestinal  actinomycosis   535 

anesthesia   55 

autointoxication    64 

catarrh   90 

hemorrhages,  in  pancreatic  cyst.125 

inflammations    72,  90 

intoxication   64,  79 

neuroses  54 

obstruction,   acute    72 

stasis   64 

torpor 60 

tumors    78 

Intussusception 72,  76 

Invagination   72 

Iridoplegia 436,  437 

Iritis,  in   syphilis 526 

Italian  leprosy    333 

Itching  around  anus,  thread  worms. 594 
Itching    of    nose    and    anus,    tape- 
worms   604  et  seq. 

skin,  in  fevers,  q.  v. 

jaundice   104 

Jacksonian  epilepsy  408,  41 1 

in  fluke  disease   601 

Jaundice  M03 

catarrhal    115 

chronic   ^..116 

hemorrhagic    528 

hepatogenous    ,.115 

infectious    566 

malignant    106 

non-obstructive   104 

obstructive    103 

Jaundice  in,  bradycardia 154 

dilatation  of  heart 154 

duodenitis   90 

febrile  icterus   567 

fluke   disease    602 


gall  bladder  diseases. ..  .116  et  seq. 

influenza    489 

liver  diseases 105  et  seq. 

malaria     *. . . .  583 

pancreatic  diseases 124  et  seq. 

potato  poisoning 336 

relapsing  fever 520,  521 

splenic  anemia    238 

syphilitic  hepatitis 523 

typhoid 480 

Weil's  disease 528 

yellow  fever   573,  574 

Jaw,  relaxed,  in  mouth  breathing.  191 

spasmodic  closure,  tetanus 532 

Jejunitis    90 

Jerking,  muscular,  in  hypertrophy 

of  heart 147 

Jerking  palsy  421 

Joint  or  joints — 

ankylosed,  in  arthritis  deformans.276 

cystic    278 

deformed,  in 

arthritides    276,  278 

gout  271,  272 

tabes  dorsalis 346 

inflamed,  in  acute  rheumatism.. 518 

lead   poisoning    329 

hemorrhagic  purpura.. 309  et  seq. 

lax,    tabes    dorsalis.. 346 

painful,  in  acute  articular  rheu- 
matism   518 

blastomycotic    anemia    239 

chronic  lymphatic  leukemia. .  .240 

tuberculous  473 

Jugular  pulse,  in  heart  block 156 

tricuspid  regurgitation   167 

June    cold 186 

Kala-azar    586 

Keratitis,   syphilis    ^ 526 

Kernig's  sign,  in  spinal  meningitis. 508 

Kidney,  diseases  of 245 

movable    261 

of  pregnancy  250 

syphilitic 523 

tuberculous   474 

tumors  of 262 

Kleptomania 401 

Koplik's  spots,  measles 557 

Kopp's  asthma   203 

Kreotoxismus    iZ6 

Kyphosis,   in   cretinism 301 

rachitis    287 

spinal   ataxia    370 

spondylitis   deformans    277 

La  grippe   489 

Lactic  acid,   in  gastric  cancer 48 

Landry's  paralysis  363 

Lamblia   588 

Laryngeal  nerve  diseases 443 

Laryngeal  spasm   444 


626 


INDEX 


as   crisis,   tabes   dorsalis 346 

Laryngismus  stridulas   203 

Laryngitis   199 

tuberculous    471 

syphilitic    524 

Larynx,  diseases  of 194 

Lassitude,   in   arteriosclerosis 173 

constipation    61 

rhinitis   183 

sleeping  sickness   589 

Lathyrism    336 

Lead  colic  328 

paralysis    329 

poisoning,  chronic  328 

acute   328 

Legs,  deformed,  rachitis 287 

osteitis  deformans   305 

swollen  in  nephritis 249 

tuberculosis 465 

Leishmaniasis    587 

Lenticular  disease 387 

Leprosy   475 

Leprosy,   Italian   (pellagra) 333 

Leprous  storms   475 

Leptomeningitis   340 

Lesions,  of  cardiac  valves 162 

Leucocytosis,  in  appendicitis. .  .96,  97 

brain  abscess  390 

empyema    225 

endocarditis    160 

erysipelas 516 

gall-bladder  diseases  ..115,  117,  120 

gastric  cancer   48 

gastritis  phlegmonous  40 

hepatic  abscess    Ill 

jaundice    104 

infantile  anemia   238 

leukemias  240,  244 

meningitis    340,  508 

obstruction  of  bowel 74 

plague    530 

pneumonia    501 

relapsing  fever   521 

scarlet  fever 552 

tonsillitis    188 

tuberculosis    468 

variola 543 

yellow  atrophy   107 

Leucopenia,  in  malaria 584 

Malta  fever    572 

measles    558 

pellagra    334 

splenic   anemia    238 

tropical   splenomegaly    586 

Leucomyelitis     345,  356 

Leukanemia    244 

Leukemias, 

lienteric   242 

lymphatic    240 

splenomyelogenous    241 


Leuco-keratosis,  mucosae  oris 23 

Leukoplakia  buccalis    23 

Leucin,  in  urine,  in  yellow  atrophy.107 
Leyden-Moebius  type  of  muscular 

atrophy    451 

Light  flashes,  in  aortic  regurgita- 
tion       165 

epileptic   aura    410 

migraine    405 

hypertrophy  of  heart 147 

Lingual  corns    23 

Lipemia,  diabetes  mellitus 281 

Lipolytic   ferment,   in  urine,  acute 

pancreati4:is    124 

Lipomatosis    290 

Lips,  diseases  of 24 

herpes,  in  acute  rhinitis 183 

Lithiasis,   gout    272 

Litigation  neuroses 404 

Little's  disease    385 

Liver,    abscess    of Ill 

actinomycotic    535 

amebic     112,  590 

anomalies  of   103 

cancer,    of 112 

cirrhosis 108 

congestion,  of  105 

diminished  in  size,  yellow 

atrophy    107 

diseases  of 103  et  seq. 

displaced    103 

drunkard's     108 

echinococcus    disease    113 

engorgement  resembling  cir- 
rhosis,- in  pericarditis 138 

enlarged,  in  amyloid  disease. ..  .114 

aortic  regurgitation  165 

autointoxication    65 

bronzed   diabetes    110 

cancer     ■. 112 

cholangitis   115,  116 

congenital  syphilis 526 

fluke   disease    600 

gout    272 

hookworm  disease   598 

cyst,   hydatid    113 

leukemia    243 

malaria    584 

mitral  stenosis   164 

rachitis    " 287 

tricuspid  regurgitation   167 

tropical    splenomegaly    586 

splenic   anemia    238 

fatty  114 

gin-drinker's 108 

hobnailed     108 

hydatid   disease    113,  606 

infested  by  flukes  600 

irregular   indurated,    in   cancer..  113 
nutmeg    108 


INDEX 


627 


scrofulous  114 

syphilis   of    523 

pulsating,  tricuspid  regurgitation  167 

tropical    578 

Lobar  pneumonia 500 

Local  asphyxia   316 

Localization  of  brain  tumor 388 

Lockjaw    532 

Locomotor  ataxia 345 

Local  syncope,  Raynaud's  disease..3l5 

Ludwig's  angina  197 

Lumbodynia    274 

Lumpy  jaw  534,  535 

Lungs,  abscess  of   221 

amebic    590 

actinomycotic    535 

blastomycotic,   confused   with 
pulmonary    tuberculosis    . .  .239 

tubercular   461 

carcinoma    of    222 

cavities,    actinomycosis    535 

tuberculosis    461 

cirrhosis 470 

collapse  of   218 

congestion    215 

fevers,  q.  v. 

malaria    583 

diseases  of   215 

embolism,  in  endocarditis 159 

fever    500 

fluke  disease  601 

gangrene,    of 221 

sarcoma  of  222 

stone    222 

syphilis,  of  523 

Lymph  nodes  enlarged  in  anthrax. 538 
cancers,  q.  v. 
fevers,  q.  v. 

glandular  fever  564 

Hodgkins'  disease    243 

lymphatic  leukemia   240 

splenomyelogenous  leukemia  . .  .241 

scrofula    471 

sleeping  sickness   589 

syphilis    522 

tuberculosis    471 

vaccination    547 

Lymphadenoid  leukemia   240 

Lymphadenoma    243 

Lymphomatus  nephritis 249 

Lymph    scrotum    596 

Lymph  vulva  596 

Lyssophobia    395 

Madura   foot 567 

Maidismus    333 

Malaria    581 

Malignancy,  after  gall-stones 121 

Malignant  pustule 537 

Malleus  humidus  536 


Malnutrition,  see  emaciation  and 
cachexia 

Malta  fever   572 

Mania,  alcoholic 324 

in  cerebral  anemia 372 

pericarditis    135 

a  potu    324 

Marble    heart    150 

Mastication,  difficult,  in  glossitis..  22 

parotitis    562 

stomatitis  16  et  seq. 

Mastitis,  in  mumps 563 

Mastodynia    427 

Masturbation,  due  to  threadworms  594 

Measles   556 

Meat  poisoning 336 

Meckel's   diverticulum    73 

Mediastinal    glands,    enlarged,    in 

anthrax    ,  538 

Mediastinum,  diseases  of 225 

Medina  worm   disease 593 

Mediterranean  fever  572 

Melaena,  in  duodenal  ulcer 45 

(See  feces,  bloody) 
Melancholy  or  mental  depression — 

in  arteriosclerosis    173 

autointoxication    ^5 

cholangitis  115 

constipation   61 

diabetes  mellitus    280 

ergotism    335 

gastric  dilatation   50 

gastritis 42 

gout    271 

hay  fever   187 

hepatic  abscess  Ill 

hyperemia  of  liver 105 

influenza 489 

jaundice 104 

osteitis  deformans   305 

paralysis  agitans    .....421 

pellagra    334 

pericarditis     135 

prostatitis    268 

tuberculosis    465 

yellow  atrophy  of  liver 107 

Melituria  279 

Membranes  in  sputum,  fibrinous 

bronchitis  ^ 208 

Membranes  in  stools,  croupous 

enteritis   92 

Membranes  on  tonsils,  acute 

tonsillitis    188 

pharyngeal  diphtheria 495 

Membranous  angina  494 

Membranous  croup   202,  495 

Memory,    lacunar,    hysteria 393 

Memory,  loss  of  in  arteriosclerosis  173 

Multiple  personality   393 

Meniere's   disease    442 


628 


INDEX 


Meninges,  diseases  of 338 

Meningeal  apoplexy   355 

Meningitis 339-342 

complicating  infectious 

fevers 490,  504,  551 

confused    with    mountain    sick- 
ness     314 

diffuse,   in   progressive  chorea.. 416 

epidemic    506 

hemorrhagic     374 

serous    341 

syphilitic   524 

tuberculous    469 

Meningomyelitis  359,  356 

Mental  defects — 

after    heat    injuries 318 

cerebral   diplegia    386 

cretinism  301 

hemiplegia  of  children 384 

hookworm  disease  598 

hydrocephalus 380 

Mental  processes  slowed,  in 

paralysis  agitans 422 

rachitis 287 

■  spinal  meningitis  508 

Mental  torpor,  in  mouth  breath- 
ing    191,  193 

Mental  irritability  in — 

basal  ganglia  tumors 389 

gastric  dilatation   50 

goiter 298,  299 

lead   poisoning    329 

lenticular  disease   387 

multiple  sclerosis 344 

snow  delirium   319 

/  (See   delirium   and   emotional 
irritability) 

Mercurialism   330 

Merycismus    35 

Metabolism,  disturbances  of.279  et  seq. 

Metrorrhagia,    purpura    310 

Micturition  painful,  in  acute 

cystitis   266 

Migraine   404 

Mikulicz's  disease   27 

Miliary  fever  568 

Milk  poisoning  336 

Milk  sickness 536 

Milky  urine,  in  filariasis 596 

Miller's  asthma 203 

Mind  blindness 435 

Mind  deafness 441 

Miner's  anemia 598 

Morbilli  556 

Morbus    sacer    408 

Morphinism    326 

Morphinomania    326 

Morvan's  disease   361 

Motor  nerves  of  eyeball, 
paralysis  of   436 


Motor  tic 419 

Mountain  sickness  314 

Mouth  breathing   190 

Mouth,  diseases  of ; . . .  16 

Mouth,  dry 26 

open    191 

tumors  of  21 

spots,   red   with   whitish    center, 

measels    557 

ulcers  in — 

canker  sore  mouth  17 

hemolytic  anemia  236 

mercurial  stomatitis    19 

vesicles,  in  foot  and  mouth 

disease    534 

(See  eruption) 

Movable  kidney 251 

Movements,  awkward,  children,  *. 

acute  chorea    415 

Mucous   casts,   in   feces,   croupous 

enteritis    92 

(See  feces) 

Mucous  catarrh  of  bronchi 207 

Mucous  colic  56 

in    vagotony    445 

Mucous  colitis    100 

Mucous  membranes,  coppery 

patches,  syphilis  522 

inflamed,    syphilis    522 

Mucous  membrane,  in  acute 

cystitis    266 

Mucous,  stools,  in  enteritis  of 

children    80,  87 

Muguet    18 

Multiglandular  diseases 308 

Multiple   sclerosis    343 

Multiplex  of  Kny 421 

Mumps  , 562 

Murmurs,  cardiac  functional — 
confused  with  lesions  of  pulmo- 
nary valves 168 

in  acute  articular  rheumatism.  .518 

autointoxication    65 

costogenic  anemia  230 

fevers,  q.  v. 

hookworm  disease  598 

hemolytic   anemia    236 

splenomedullary  leukemia 243 

neurasthenia    401 

scurvy    290 

Murmurs,  cardiac  organic — 

aortic    166,167 

endocardial    158 

mitral    164,    165 

pulmonary    168 

tricuspid  167,  168 

Muscles,  disorders  of 447,  452 

Muscular  atrophy  in 365 

amyotrophic   lateral   sclerosis. .  .367 
arthritis   449 


INDEX 


629 


infantile   paralysis    510 

lead   poisoning    329 

neuritis     431 

myasthenia  gravis    451 

Muscular  cramp,  in — 

bony  lesions 407 

cholera  576 

ergotism    335 

heat  injuries 317 

Muscular  dystrophies  450 

Muscular  lesion    447 

Muscular  spasms  or  twitchings,  in — 

chorea   415,  416 

epilepsy   408 

hemiplegia    of   children 384 

hydrophobia    530 

lenticular  disease   387 

meningitis    470,   508 

myelitis .359 

myotonia  congenita 450 

neuralgia .426 

neuritis     430 

paramyoclonus   multiplex    421 

primary   athetosis    452 

tetanus    532 

tetany  303 

Muscular  tremor,  in — 

exophthalmic  goiter    298 

paralysis   agitans    422 

senile  states  452 

toxic   states    452 

Muscular  weakness,  in — 

cerebellar  diseases  389 

myelitis    359 

(See  muscular  atrophy) 

Mushroom  poisoning   336 

Mussel    poisoning    336 

Myalgia   , 274 

Myasthenia  gravis  451 

Mycetoma    567 

Mydriasis    436 

Myelitis    356 

chronic    358 

infectious   357 

compression    358 

disseminated    349 

Myeloid  leukemia 242 

Myiasis    592 

Myocarditis    141 

after  acute  articular  rheumatism. 518 
Myocardium,  diseases  of...  141  et  seq. 

Myoclonus  fibrillaris 421 

Myoclonus  multiplex    421 

Myokymia,  fibrillary   421 

Myospasm,  due   to   heat 317 

Myosis    436 

Myositis   274 

infectious   448,  449 

oslsificans    448 

paratyphoid    486 


Myotonia   ,...  ,451 

atrophic   451 

congenita     450 

Oppenheim's i 451 

Mysophobia   401 

Myxedema  300 

atrophic    301,  302 

congenital   301 

following  goitre    297 

acute  thyroiditis   295 

Myxoneurosis  intestinalis   56 

Nails,  thickened,   neuritis 430 

Nasal     membrane,     red,     inflamed, 

nodular,   purulent,   glanders 536 

Nasal  discharge,  local,  pus,  gland- 
ers     536 

hard  crusts,  foul  odor,  in  ozena.  185 

offensive,  bloody,  diphtheria 495 

thick,    tenacious,    mucous,    in 

chronic  rhinitis   184 

thin,  watery,  acute  rhinitis 183 

Natal  sore    587 

Nausea  and  vomiting,  in — 

Addison's    disease 307 

alcoholism    325 

anaphylaxis    321 

anthrax    538 

aneurysm    of   hepatic   artery. ..  .177 

aortic  aneurysm   176 

appendicitis    96 

arteriosclerosis    173 

autointoxication    65 

biliary  colic    119 

cerebellar  disease  389 

cerebral    anemia     : . . .. 372 

chicken    pox    548 

cholera    575 

cholera  morbus 93 

colitis   94 

dengue   571 

desert  sickness   320 

delirium  tremens  : 325 

endocarditis     160 

enteritis    79,  90 

epilepsy,  aura    410 

erysipelas   515 

exophthalmic  goiter   298 

gastric  diseases   33-50 

gall-bladder  diseases   115-117 

gall-stones 119 

glandular  fever  564 

gout    272 

hemiplegia    of    children 384 

hemolytic  anemia 236 

influenza 489 

infantile  paralysis 511 

jaundice    104 

Landry's  disease 364 

lead  poisoning 328 

liver  diseases   107-111 


630 


INDBX 


malaria   582  et  seq. 

mastodynia   427 

meningitis    ....'. 469,   507 

migraine    405 

milk  sickness  536 

myelitis    , 357 

nephritis  249,  250,  252,  255 

obstruction   7i 

pancreatic  diseases  123,  126 

pericarditis    135 

peritonitis 130,  131 

pertussis   492 

pleurisy    i 223 

poisoning,  food   336,  3i7 

purpura    310 

proctitis    101 

relapsing  fever  520,  521 

scarlet  fever 550 

simple  fever 320 

strangulation    75 

tapeworms    603    et    seq. 

trichinosis  597 

typhoid  , 479 

vagus,  irritation  of   445 

variola    541 

yellow  fever  574 

Neapolitan  fever    572 

Neck  muscles  rigid  in — 

infantile  paralysis   511 

diphtheria    495 

tongue  diseases 21 

tetanus  532 

Negri  bodies,  in  hydrophobia  530 

Nematodes   593 

Nephritis   248-257 

in   arteriosclerosis    173 

chicken    pox    549 

diphtheria 496 

glandular  fever  565 

hemorrhagic  jaundice   528 

influenza    490 

meningitis  508 

pneumonia    504 

scarlet  fever 550,  555 

typhoid    480,   484 

yellow  atrophy   107 

Nephrolithiasis    258 

Nephroptosis   261 

Nervous  disturbances  in  floating 

kidney    262 

Nerve  fibers,  regeneration  of 432 

Nervous  system,  diseases  of  Part 

VII    338 

Nervous  system,  syphilis  of 524 

Neuralgia  425 

cardiac     150 

ce.rvico-brachial    427 

femoral   428 

genito-crurual 428 

hypogastric   55 


intercostal    427 

intestinal    55 

lumbo-abdominal    428 

obturator     428 

occipital     427 

visceral   428 

Neurasthenia    400 

cardiac  type  400 

cerebral  type   401 

gastric  type   400 

sexual    type    400 

treatment    402 

vaso-motor  type 400 

Neurasthenic   states    398 

confused   with   early   paralytic 

dementia    348 

in  aortic  regurgitation   166 

chronic  prostatitis   268 

Neuritis 428 

epidemic    566 

optic .•••••. ^"^5 

Neuritis,   in   beri-beri 566 

arsenic  poisoning  331 

diabetes  mellitus    280 

gout 272 

heat   injuries    318 

influenza    490 

lead  poisoning 329 

pneumonia    505 

typhoid    480 

variola 543 

Neuroglia,  overgrowth  of,  multiple 

sclerosis    343 

Neuromata   431 

Neuroses,  cardiac  153 

of  the  bladder 264 

gastric    33 

intestinal    54 

occupational 406 

traumatic     ." 403 

Nerve  fibers,  regeneration  of 432 

Night-blindness    434 

in  scorbutus  289 

Night  terrors  in  acute  chorea 415 

adenoids    191 

chronic   entero-colitis   of 

children     87 

Nitrogenous  wastes  in  urine  in 

renal   calculus    .....259 

Nocturnal  epilepsy,  in  enuresis. .  .265 

Nodding  spasms,  of  infants 421 

Nodules,   leprous    475 

Noises  in  abdomen,  see  Neuroses, 

of  stomach  i2>  et  seq. 

Noma  20 

Nose  bleed   180 

Nose,  broad,  in  mouth  breathing.  .191 

purple,   in   relapsing   fever 521 

red    186 

tumors,  of  goundon 568 


INDEX 


631 


Nostrils,  nodules  around,  glanders.S36 

Nyctalopia    434 

Nymphomania,   hysteria    394 

Nystagmus   437 

in  cerebellar  disease 389 

spinal   ataxia    370 

multiple  sclerosis   344 

Obesity    290 

hypophyseal    291 

pineal  disease 308 

treatment   291,  292 

typhoid    484 

see  also  hypophysis  adiposity. .  .305 
Obstruction  of   intestine — 

acute    72 

chronic    77 

gall-stone    120 

intestinal  tumors   78 

paretic    77 

Occupational  neuroses  406 

Odor,  foul,  sputum  in  brochectasis  210 

body  in  variola 541 

musty,  mouse-like,   typhus. ..  .487 
putrid,  cancer,  gangrene,  q.  v. 
sweetish,  diabetes  niellitus. .  .  .280 
(See  breath) 

Oinomania    324 

Olfactory  nerves    433 

Oliguria,   acute   enteritis 91 

Ophthalmos,  relapsing  fever 521 

Ophthalmoplegia    437 

Opisthotonos,  in   spinal 

meningitis    341,   507 

tetanus    532 

Opium  narcosis    326 

Optic    chiasm,    lesion 435 

Optic  nerves,  diseases  of 433 

Optic    nerve    atrophy 435 

multiple    sclerosis    344 

tabes   dorsalis    346 

syphilis    525 

Optic  tracts,  lesion 435 

Optic  neuritis    435 

Orchitis,   in   malaria 584 

parotitis 563 

typhoid    480 

Oriental  sore  587 

Orthopnea,  in — 

broncho-pneumonia  213 

chronic  spleno  medullary 

leukemia    243 

pulmonary,  edema   217 

Orthotonus,  tetanus    532 

Osteitis   deformans    , 305 

Osteophytes,    in    arthritis 278 

Otitis  media,   in   chickenpox 549 

diabetes   mellitus vi^nv 280 

diphtheria    . ..  Mim-t  --i' 496 

glandular  fever 565 

influenza    490 


measles  558 

rubella    561 

scarlet  fever 551 

vaccination   547 

variola    543 

Ovaritis,   parotitis    563 

Oxygen  treatment,  for  syphilis. .  .527 

Oxyuris  vermicularis 594 

Ozena    185 

Pachymeningitis    339 

Pain,  or  distress — 

absent  in  most  syphilitic  lesions. 523 
fleeting,  in  autointoxication....  65 
lightning,  in — 

diabetes  mellitus    280 

tabes   dorsalis    346 

sense,  lost  in  syringomyelia.. .  .360 
neuralgic,  in  caisson  disease.. .  .363 

meningitis     340 

myelitis    358 

neuritic  in  meningomyelitis 359 

noctural,   in  pancreatic   cancer..  126 

sharp,  in  neuralgia 426 

suboccipital,  in  tongue  diseases.  21 
Pain,   in   abdomen,   colicky,   in — 

cholangitis  115 

colic 55-59 

dysentery  569,  590 

intestinal  inflammations 79-100 

intestinal   tumors    78 

lead  poisoning 328 

tapeworms  603  et  seq. 

Pain,  in  abdomen,  sudden,  sharp,  in — 

aneurysm    of    splenic    artery 177 

hepatic  artery   177 

Dietl's  crisis  in  floating  kidney. 262 

embolism    of    kidney 263 

gall-stones    119 

hemorrhage  or  perforation,  in 

typhoid    480 

appendicitis   96 

obstruction    73 

renal    calculi    . .  ^ 259 

Pain,   in   abdomen,   sudden    cessa- 
tion, in  appendicitis 97 

gall  stones 119 

renal  calculi  259 

Pain,  abdomen,  in  epigastric 
region,  in — 

cholangitis IIS 

gastric  neuroses    33,  34 

gastric  organic  diseases  38,  42,  48,  50 
fevers,   q.  v. 

malaria 582  et  seq. 

pancreatic  disease 124-126 

tuberculosis    467 

Pain,  abdomen,  general  or  variable,  in 

actinomycosis  535 

cholera 575 

constipation    61 


632 


INDEX 


enteralgia  55 

gastro-enteroptosis    69 

gout  272 

hepatic  diseases  107-1 10 

intestinal    inflammations 79-100 

lead  poisoning 328 

obstruction    77 

pancreatitis    125 

peritonitis    130-133 

purpura    310 

tuberculosis    472 

Pain,  abdomen,  hepatic  region,  some- 
times including  right  shoulder  and 
scapula,  in — 
aneurysm  of  hepatic  artery...  177 

duodenal  ulcer    45 

endocarditis    160 

gall-bladder  diseases   116-121 

hepatic  diseases 108-1 12 

hydatid    cyst    113 

preceding  pancreatitis    124 

psorospermiasis     589 

pubic  region  or  loins  radiating,  in — 

cystitis 267 

constipation    61 

floating  kidney   262 

hydronephrosis   260 

nephritis    249 

perinephric  abscess  260 

prostatitis    268,  269 

pyelitis  257 

renal  calculi  259 

renal  hyperemia   247 

renal    tumors    262 

rectum,  coccyx  or  perineum,  in — 

coccygodynia  428 

colitis   94 

constipation   61 

enteralgia  55 

proctitis  101 

prostatitis   268 

vagotony   445 

splenic  region,  sometimes  includ- 
ing left  shoulder,  in — 

endocarditis    160 

splenic  anemia    238 

malaria   381  et  seq. 

splenitis    313 

umbilical  region,  in — 

obstruction,   7i 

strangulation    75 

Pain,  in  back,  thoracic  region,  in — 

aortic  aneurysm   176 

autointoxication    65 

fevers,  q.  v. 

cholecystitis    117 

gall-stones    120 

gastric  diseases 33-48 

liver  diseases 105-11,   578 

meningitis  341 


pericarditis   135 

Pain,  back,   lumbar   region   in — 

cystitis   267 

diabetes  insipidus 283 

diabetes  mellitus    280 

fevers,   q.   v. 

food  poisoning   32)7 

malaria     584 

meningomyelitis    359 

myelitis    357 

nephritis    250 

Pain,  of  bones,  in  dengue 571 

mercurialism    330 

osteitis  deformans  305 

scorbutus     289 

syphilis   522,  523 

Pain,  in  chest,  general  or  variable,  in 

anthrax    538 

food  poisoning  337 

hepatic  diseases  106  et  seq. 

lung  diseases 215,  467,  501 

pleuritic   diseases    223-225 

pleurodynia 275 

Pain,  chest,  precordial,  in — 

angina  pectoris   150 

cardiac  diseases  135-165 

cardiospasm   31 

esophagus  diseases  30,  31 

gout    272 

Pain,  chest,  substernal  in — 

aneurysm    175 

.  bronchitis    205 

tubercular   lymph    nodes 471 

Pain,  in  eyeball — 

cephalodynia    274 

chloroma  239 

face — 

neuralgia   426 

near  ear,  mumps 562 

fingers  and  toes,  ergotism 335 

fingers,   Raynaud's  disease 315 

healed  wound,  hydrophobia 531 

head,  see  headache 
joints,    in — 

acute  articular  rheumatism.517,  518 

arthritis   277 

blastomycotic  anemia  239 

lead   poisoning    329 

leukemia    241 

purpura 309  et  seq. 

lips    24 

mouth,  stomatitis 16  et  seq.  26 

muscles,  in — 

autointoxication 65 

caisson  disease  I'i.  VI . .'. 363 

heat  cramps  .  '.'I  i 317 

infantile  paralysis   511 

hemorrhagic  jaundice   528 

rachitis    286 

rheumatism    274 


INDEX 


633 


scurvy   289 

tetanus  532 

torticollis    274 

trichinosis   597 

muscles  of  mastication,  in — 

cephalodynia    274 

glossitis   22 

mumps   562 

stomatitis   16  et  seq. 

Pain,  nerve  trunks,  neuritis   429 

gout 271 

tongue,  in  glossitis 22 

tonsils,   herpetic  tonsillitis 188 

Palmus   419 

Pallor,  in — 

anemias 229  et  seq. 

cardiac  diseases. .141,   151,   158,   163 

heat  exhaustion    318 

hemorrhages,  q.  v. 

leukemias 241  et  seq. 

nephritis  256 

neurasthenia    400 

(See  cachexia) 

Palpable  kidney   261 

Palpitation  of  heart 154 

in   autointoxication    65 

chlorosis    233 

gastric  dilatation    50 

chronic  gastritis 42 

hemolytic  anemia 235 

hookworm  disease   598 

mitral   lesions    163 

Palsy,  Bell's 439 

Pancreas,  cancer  of 126 

Pancreas,    diseases    of 123 

Pancreatic  calculi 127 

Pancreatic  cysts   '. 125 

Pancreatitis 124,  125 

Papilledema    434 

Parageusia    438 

Paralysis  agitans   421 

Paralysis,  Brown-Sequard,  in 

meningomyelitis   359 

Paralysis,  Bell's   439 

facial    439 

general  347 

infantile  510 

intestinal    72,  77 

Landry's    363 

laryngeal    444 

periodic    453 

temporary,  without  aphasia .453 

Paralysis,  in  anaphylaxis 321 

aortic  aneurysm   176 

apoplexy    375 

arteriosclerosis    173 

beri-beri     566 

caisson  disease   363 

diphtheria    496 

ergotism    335 


heat   injuries    318 

hemolytic  anemia 236 

hydrophobia     531 

hysteria    . . . ; ; 393 

lateral  sclerosis 369 

lead  poisoning 329 

leprosy    475 

malaria   583  et  seq. 

meningitis 341,  470,  508 

myelitis  357,  359 

mercurialism    330 

neuritis    430 

relapsing  fever   521 

syphilis    525 

syringomyelia  361 

vaccination 547 

variola    543 

Paralytic   dementia    348 

Paramyoclonus  multiplex   421 

Parasites,  table  of  localization 579 

Paraplegia,  Erb's  358 

Parasyphilitic  diseases   525 

Parathyroids,  disease  of 303 

Parathyroids,  in  paralysis  agitans. 422 

Paratyphlitis    95 

Parenchymatous  hepatitis 106 

Paresthesias,   before    cerebral 

hemorrhage    375 

Paresthesias,  in  beri-beri 566 

delirium  tremens    325 

diabetes   mellitus    280 

hemolytic  anemia  236 

meningitis   340,  342 

myelitis 358 

tetany    303 

Paretic  obstruction,  of  intestine..  77 

Parkinson's  disease   421 

Parosmia    433 

Parotid    bubo,    typhus 487 

Parotitis    , 27,    562 

Peliosis   rheumatica    310 

Pellagra ZZZ 

Peptonuria,  empyema  225 

Perforation,   in   peptic   ulcer 44 

Perforation  typhoid    480 

Pericarditis  135 

callosa    138 

in  acute  articular  rheumatism. .  .518 

pneumonia  505 

Pericardium,  diseases  of 135 

tuberculosis  of    474 

Pericecal  abscess  95 

Peripheral  nerves,  diseases  of.... 424 

Periodic  paralysis    .453 

Peristaltic  unrest  35 

Peritoneum,  disease  of 128  et  seq. 

Peritonitis,  actinomycotic   535 

acute  129 

chronic 132 

malignant    133 


634 


INDEX 


subphrenic    131 

tubercular  472 

Peritonitis,   complicating — 

appendicitis 96 

biliary  colic 119 

cholecystitis   .  ^ 117 

hepatic  cancer  112 

obstruction    of    bowel_ 7i 

tropical  dysentery   . . .' 570 

typhoid    480 

Peritonsillar  abscess 190 

Perityphlitic  abscess 95 

Perleche    25 

Pertussis  491 

Petit  mal  408,  411 

Petit  mal  in  enuresis 265 

Petit  mal,  imitated  in  chronic 

entero-colitis  of  children 87 

Phagedena  tropical  567 

Pharyngeal    nerve    lesions 443 

Pharyngitis    195 

Pharynx,  disease,  of 194 

spasm,  in  tetanus  532 

Phlebectasia    178 

Phlebosclerosis 174 

Phlegmasia  alba  dolens,  in  typhoid  480 

Phosphaturia,  in  neurasthenia 401 

Photophobia,  in  cerebral 

leptomeningitis   341 

tuberculous  meningitis 470 

Phthisis 466 

Phthisis,  after  influenza 490 

Picking  at  nose,  worms      594  et  seq. 
Pigeon  breast,  in  mouth  breathers  191 

rachitis    287 

Pigmentation,   in   multiglandular 

disease   308 

Pigmented  nodules,  in  skin, 

hepatic  sarcoma   113 

(See  skin) 

Piles,  in  constipation 61,  63 

Pineal  body,  disease  of 308 

Piroplasmosis    586 

Pituitary   body,    disease   of 304 

diabetes  insipidus  283 

Pitting,  in  chickenpox 549 

in  variola 545 

of  epigastrium,  in  yellow 

atrophy    107 

Plague   529 

Plaques,  on  tongue,  in  chronic 

stomatitis   20 

leucoplakia   buccalis    23 

Pleurisy 222-224 

in   pneumonia    505 

acute   articular   rheumatism 518 

Pleuritis 222 

Pleuritic  abscess 224 

Pleurothotonos,  in  tetanus 532 

Plumbism   328 


Pneumogastric  nerve,  lesions  of.  .443 

Pneumokoniosis    221 

Pneumonia   500 

chronic    interstitial    470 

lobar    500 

lobular 212 

Pneumonia,    confused    with    acute 

pulmonary  tuberculosis   466 

Pneumonia,  sequela  of — 

cholera    576 

diphtheria    496 

influenza    489 

measles    558,    560 

meningitis  / 508 

rubella    561 

stomatitis  20 

typhoid  480,  484 

variola 543 

whooping  cough 492 

Pneumonitis 500 

Pneumopericardium   140 

Pneumothorax 225 

Poisoning,  alcohol ' 323 

arsenic    330 

cocaine    328 

foods,  improper  Zi2  et  seq. 

headache  medicines 331 

lead    328 

mercury    19,  330 

morphine    326 

opium    326 

(See  etiology,  drugs) 

Poliomyelitis   356 

Poliomyelitis,  anterior,  acute 510 

Polyarthritis,  chronic  infectious. .  .276 

Polycythemia   239 

in    diabetes   mellitus 280 

diabetes  insipidus 283 

Polyglandular  disease,  see 

pages   298,  308 

Polymyositis   448 

Polyps,  intestinal    76,  78 

nasal  185 

Polysarcia  adiposa  290 

Polyserositis    140 

Polysystole 155 

Polyuria,  in  diabetes  insipidus 283 

diabetes  mellitus    279 

multiglandular  disease 308 

Pons,  hemorrhage  of  376 

Pontine  tumors   389 

Pork  tape  worm 604 

Portal  circulation,  in  hepatitis 108 

Potato  poisoning  336 

Pott's  disease    473 

Pregnancy,  in  vesical  hemorrhage. 268 
Priapism,  in  chronic  splenomedul- 

lary  leukemia  242 

threadworms    594 


INDEX 


635 


meningomyelitis   359 

spinal  meningitis  508 

Primary  athetosis    452 

Proctitis    101 

Prolapse,  of  rectal  membrane, 

proctitis   101 

Prolapsus   ani,   infectious   enteritis 

of  children   84 

Prostate,  carcinoma,  of 269 

Prostration,  in — 

angina    pectoris    151 

anthrax    538 

cholera     575 

cholecystitis     117 

diphtheria 495,  496 

enteritis  of  children 82 

glanders    536 

gout 272 

heat    injuries    317 

influenza    489 

malaria 584  et  seq. 

perinephric  abscess   260 

plague    529 

potato  poisoning   Z2>6 

typhus    487 

variola     541 

protozoan  infections. ..  .581   et  seq. 

Pruritis,  in   diabetes  mellitus 279 

trichonomas  disease 588 

nephritis    256 

Pseudo-appendicitis    97 

Pseudohermaphroditism 304 

Pseudohydrophobia ! 395 

Pseudohypertrophic   muscular 

atrophy    450 

Pseudomeningitis,   hysteria    395 

Pseudo-leukemia 243 

Pseudo-Raynaud's    disease 315 

Pseudosclerosis    343 

Psilosis  567 

Psorospermiasis    589 

Psychoanalysis  in  hysteria 395 

Psychasthenia    401 

Psychic  epilepsy  411 

Ptomaine    poisoning    2)2t7 

Ptyalism    26 

mercurial  19 

Puberty,  premature,  in   disease  of 

pineal   body    308 

Pulmonary  apoplexy 216 

congestion    215 

in   endocarditis    158 

regurgitation    ... ., 163 

edema 217 

gangrene   221 

valves,    stenosis    168 

regurgitation    168 

Pulsation,  epigastric,  hypertrophy 
of  right  ventricle  147 


Pulse- 
capillary,  in  aortic  regurgita- 
tion    166 

Corrigan's  in  aortic  regurgita- 
tion  166 

dicrotic,  in  typhoid   479 

feeble,  in — 

dilatation  of  heart 145 

morphinism    326 

typhus,  late    487 

irregular,   in  arrhthymia.. 155 

acute  thyroiditis  296 

convalescence,  many  diseases. 

goiter   297 

mitral  lesions  .163,  164 

pericarditis   135 

jugular,  in  heart  block 156 

tricuspid  regurgitation   .......167 

rapid,  in  arthritis  277 

exophthalmic  goitre    298 

lateral  sclerosis 369 

tachycardia    154 

yellow  atrophy  107 

pituitary  body  disease 304 

often  dicrotic,  in  acute  fevers,  q.  v. 

rapid,  feeble,  in — 

acute  food  poisoning 2Z7 

cardiac  asthma   157 

endocarditis    158 

mitral   stenosis    164 

myocarditis  141,  142,  145 

pericarditis 135 

slow,  in — 

alcoholism   324 

bradycardia     154 

fatty  heart 144 

jaundice   103,   104 

lead   poisoning 328 

late    yellow    fever 573 

venous,  see  jugular 

water  hammer,  in  aortic  regurgi- 
tation     166 

.   hemolytic  anemia 236 

Pulsus  alternans    156 

bigeminus    156 

paradoxus   ,.138. 

tardus  167 

trigeminus     156 

Pupil,  or  pupils — 

Argyll  Robertson,  in — 
parasyphilitic  diseases.. .  .346,  349 

comma,  in  tabes  dorsalis 346 

contracted,  in  enteritis  of 

children    83 

tuberculous    meningitis    470 

early  typhus  486 

dilated — 

acute  food  poisoning 3Z7 

Raynaud's    disease    315 

late  typhus  487 


636 


INDEX 


Pupillary   disturbances,   in   brain 

tumor   388 

aortic  aneurysm  176 

morphinism   326 

myelitis    349 

tabo-paralysis    349 

Pupillary  reflex  lost,  in  fermental 

enteritis  of  children 83 

Pupils  dilated,  in  simple  goiter. . .  .297 

Purging,  in  cholera  morbus 93 

fermental  enteritis  of  children..  82 

malaria,  choleraic  583 

(See  diarrhea) 

Purpura  309 

hemorrhagica 310 

scorbutic    289 

in  acute  articular  rheumatism. .  .518 

tropical    splenomegaly 586 

Purpuric    hemorrhages,    in 

endocarditis    159 

Pus,  blebs,  on  face,  erysipelas 516 

in  feces,  in  chronic  obstruction..   77 

proctitis    101 

vomitus,  in  gastric  cancer 49 

phlegmonous  gastritis   40 

Pustule,  vaccination    546 

Putrid  sore  mouth 18 

Putrid   sore   throat 494 

Pyelitis  calculus  258 

Pyelonephritis  257 

Pyemia,  typhus  487 

Pyloric  obstruction  49 

spasm  35 

stenosis    49 

Pyonephritis    257 

Pyorrhea  alveolaris 25 

Pyrosis,  chronic  gastritis 42 

hyperchlorhydria    3i 

Pyramidal    tracts,     imperfect     de- 
velopment of.  cerebral  diplegia. 385 
Pyuria  in  disease's  of  urinary 

system    246 

Quinsy   190 

Rachitis  286 

Raynaud's  disease   315 

Rectal  tenesmus,  in  prostatitis 268 

Rectitis    101 

Rectum,  catarrh  of  101 

Regeneration  of  nerve  fibres 432 

Regurgitation  in  carcinoma  of 

esophagus   30 

stricture     31 

Relapsing  fever 520 

Remissions,  in  multiple   sclerosis. 344 

Ren  mobilis   261 

Renal  calculus 258 

Renal   colic    258 

Renal  neuroses   258 

Respirations,   slow   in   jaundice. .  .104 
morphinisrti    326 


stertorous,  morphinism   327 

(See  breathing) 
Restlessness,  in  hypertrophy  of 

heart  147 

rachitis 286 

Retching,  in  stricture  of  esophagus  31 

Retina,  diseases  of 433 

Retinal    hemorrhages 434 

in  syphilis  525 

Retinitis   434,  255 

Retropharyngeal   abscess    196 

Rheumatism,  acute  articular   517 

articular    276 

after  erysipelas  516 

muscular   274 

subacute    518 

Rhinitis,  acute  183 

influenza    489 

measles    557 

whooping  cough  492 

Ribs,  in  blood  formation 227 

Rickets    286 

Rickets,   late    288 

obesity,  in  late  rickets 288 

Riga's  disease   21 

Rigidity,  of  abdominal  muscles, 
especially    right    rectus,     in 

appendicitis   96 

of  skeletal  muscles,  in  cerebral 

diplegia  385 

of  spinal  column,  in  arterioscle- 
rosis   172 

neurasthenia    399 

senility  380 

spinal  meningitis   341 

typhoid   478,  483 

Rigg's  disease  64 

Rock  fever  572 

Rocky  Mountain  fever 587 

Romberg's   sign,  tabes  dorsalis. .  .346 

Rosary,  rickets   287 

Rose  cold  / 186 

Rotheln   560 

Roimd  worms  595 

Rubella    560 

Rubeola  556 

Rumination    35 

Sago  spleen   313 

Sailor's  fever  573 

St.  Anthony's  dance 414 

St.  Anthony's  fire 515 

St.  Vitus'  dance   414 

Saliva,  acid,  in  acute  articular 

rheumatism    518 

Saliva,  increased,  in 

stomatitis    16  et   seq. 

Salivary  glands,  diseases  of 26 

Salivation,  in  mumps 562 

foot  and  mouth   disease 534 

gastralgia    34 


INDEX 


637 


mercurialism  330 

mushroom  poisoning   336 

variola    542 

Sarcoma,  in   orbit 239 

Saturnism   328 

Satyriasis,  hysteria    394 

Scapulae,  winged,  in  muscular 

atrophy  450 

Scarlet  fever   549 

Scars,  coppery  hue,  syphilis 523 

Sciatica    428 

in  carcinoma  of  prostate 269 

Scissors  gait,  cerebral  diplegia  ...386 

Schonlein's  disease    310 

Sclerosis,  multiple  343 

Sclerosis  of  veins 174 

Sclerosis    of    liver 108 

Scolecitis    95 

Scotoma,  central   433 

Scorbutus    289 

Scrofula    471 

Scrofula,   in   tuberculous 

meningitis    469 

Scurvy   289 

Alpine  (pellagra)   133 

infantile  289 

Seasickness    314 

Secretions,   disturbances  of, 

stomach   33 

Senile  dementia 379 

Senility,  premature 379 

Sensation,  disturbances  in 

autointoxication    65 

Sensations    393 

girdle,  in  tabes  dorsalis 346 

girdle,  neurasthenia 400 

stocking,  neurasthenia   401 

Sick  headache  404 

Siderosis    222 

Sighing,  in  myocarditis 141 

Sighing,  in  chlorosis 233 

Sinus  irregularity  156 

Siriasis    316 

Sitotoxismus 335 

Skeletal  muscles,  diseases  of 447 

Skin,  actinomycosis,  of 535 

abscesses,  in  acute  farcy 537 

Skin,  color — 
bronzed,   in   Addison's   disease.. 307 

diabetes    299 

exophthalmic  goiter    299 

patches,  leprosy 475 

brownish,  thickened,  in  Gaucher's 

disease   238 

brown  nodules,  hepatic  sarcoma.  113 

brown  patches,  arthritis 277 

earthy,  in  hookworm  disease. ..  .598 

infantile  scurvy  289 

malaria 584 

pancreatic  disease   125 


syphilis    526 

greenish   yellow,   chlorosis 232 

lemon  yellow,  hemolytic  anemia.236 

muddy,  hyperemia  of  liver 106 

putty-colored,  cirrhosis  of  liver.  109 
sallow,    in   autointoxication    ....  63 

costogenic  anemia   231 

gall-stones    119 

scorbutus    289 

wrinkled,  itchy,  in 

morphinism    326 

waxy,    in    arsenicism    331 

yellow,  in  jaundice 103 

cholangitis  115 

gastric  cancer  /. 48 

desquamating,  in  gout ♦. 271 

dry,  harsh,  itchy,  in  diabetes 

mellitus    280 

dry,   scabby  sores,  in  blastomy- 
cosis     239 

dry,  in   tropical  dysentery 570 

emobolism,   in   endocarditis 159 

hardened,  in  acromegaly 304 

like  sunburn,  in  pellagra 334 

nodules,  in  acute  articular 

rheumatism    518 

farcy    536 

pigmented  in  hepatic  sarcoma...  113 

pitting,  variola    543 

rose  colored  spots,  abdomen, 

typhoid   479 

shining,  in  neuritis 430 

thickened,  exophthalmic 

goitre    299 

tropic  changes  in  neuralgia 426 

(See  edema  and  eruption) 

Skolikoiditis    95 

Skull,  square,  children,  rachitis. .  .287 

bosses,  rachitis 287 

(See  head,  enlarged) 
Sleep  disturbances,  children,  acute 

chorea    415 

interstitial  nephritis 255 

rachitis    287 

(See  insomnia) 

Sleeping  sickness  588 

Sleep  start,  mitral  regurgitation. .  .163 

Smallpox    540 

Smells,  aura  of  epilepsy 410 

Smell,  disturbances 433 

in  hysteria    394 

Sneezing,  in  hay  fever 187 

influenza  489 

rhinitis    183 

Snow  blindness  and  delirium 319 

Softening   of   brain 376 

Solitary    abscess 112 

Somnambulism,  in  hysteria 393 

Somnolence,  in  congestion  of 
brain    373 


638 


INDEX 


hemolytic  anemia    236 

Sordes,    in    typhoid 479 

typhus    487 

Soor 18 

Sore  arm,  in  vaccination 547 

mouth    17,  18 

throat    195 

throat,  scarlet  fever.. 550 

Sounds,  aura  of  epilepsy 410 

Spasm   or   spasms — 

convulsive,  in  children 417 

habit    419 

in  meningitis  342 

of  coronary  arteries 150 

esophagus 31,  272 

facial  muscles 439,  341 

glottis    203 

intestines    55,  72 

limb   muscles,   tetanus .532 

muscles  of  mastication,  fifth 

nerve    438 

pylorus    35 

right  rectus,  appendicitis 96 

cholecystitis   117 

rapid,  not  producing  movements.421 

Speech,  awkward,  before   cerebral 

hemorrhage 375 

drawling,  in  multiple  sclerosis.  .344 

difficult,  in  bulbar  palsy. 366 

difficult,   in   glossitis 22 

disturbances  in,  progressive 

chorea    416 

hesitating,  tumors  of  basal 

ganglia  389 

involuntary,  in  general  tic 420 

loss   of,   apoplexy    375 

scanning,  in  multiple  sclerosis.  .344 

Sphincters,    paralyzed,    typhus. ..  .487 

Spinal  accessory  nerve,  lesions  of. 445 

Spirochetes,    disease   due   to 520 

Spinal  apoplexy   355 

cord,  compression  of 358 

cord,  diseases  of   351 

fever  506 

meningitis   339-342,  469,  506 

Spinal  progressive   muscular 

atrophy    365 

Spinal   rigidity  after   infectious 

enteritis  of  children 86 

Spirochetes,  in  hemorrhagic 

jaundice     528 

relapsing  fever   520 

syphilis   521 

Splanchnoptosis    68 

Splashing  noises,  due  to 

pneumopericardium   140 

Spleen,    diseases    of 312 

embolism  of 312,  159 

enlarged,  in — 
anthrax    538 


arthritis   278 

autointoxication    \..  65 

cholangitis    115 

chloroma  239 

enteritis    91 

Gaucher's  disease  238 

Hodgins'  disease    243 

hookworm    disease    .^98 

infantile  anemia    238 

leukemia  240.  241,  243 

malaria    584 

Malta  fever 572 

plague   529 

polycythemia   239 

rachitis 287 

splenic  anemia    238 

status  lymphaticus,   children.  .313 

syphilis    523,  526 

tropical    splenomegaly    586 

typhoid   479 

typhus  487 

yellow  atrophy   107 

Spleen,  tumors  of 313 

Splenic  anemia   238 

apoplexy    537 

fever  537 

Splenitis    312 

Spleno-medullary    leukemia 242 

Splenomegaly    238 

Splenomyelogenous  leukemia. 241,  242 

Spondylitis  deformans  277 

Sporadic   cholera    93 

Spots,  red,  upon  nose  and  over 

malar    bones,    erysipelas 515 

Spotted  fever 506,  587 

Sprue    567 

Sputum — 

bloody,  in  malaria 583 

(See    hemoptysis) 

profuse,    watery,   plague 529 

thin,  pulmonary  edema 217 

containing  bile,  frothy,  abscess 

from  liver  into  lung 221,  523 

black  shreds,  syphilitic 

laryngitis 523 

eggs  of  flukes 601 

offensive,  actinomycosis 535 

profuse,  in  bronchiectasis 209 

purulent,  subphrenic  peritonitis.  131 

rusty,  pneumonia   502 

viscid,  in  broncho-pneumonia. .  .213 
becoming  purulent,  bron- 
chitis    206,  207 

Stammering,  tic   419 

Status  lymphaticus    313 

Status   epilepticus    408,   410 

Stenocardia    150 

Stenosis,    of    esophagus 31 

pylorus    49 

Stillbirths,  syphilis 525 


INDEX 


639 


"Stitch  in  side,"  pleurisy   223 

Stokes-Adams  disease 156 

Stomach,  diseases  of 33  et  seq. 

abscess    40 

cancer    46 

dilatation    49 

neuroses    33 

orcranic  diseases 38 

Stomatitis 16,  20 

Stomatitis,  in  chickenpox 548 

chloroma    239 

measles    558 

mercurialism    , 330 

sprue    567 

scorbutus    289 

Stools,  see  feces 

Strabismus   437 

Strabismus,  in  cerebellar  disease.. 389 

cerebral    leptomeningitis 341 

Strangulation    72 

Stricture,  of  esophagus 31 

intestine     77 

congenital   72 

Stridor,   aortic    aneurysm 176 

Strumitis    295 

Stupor,   in   alcoholism 324 

broncho-pneumonia  213 

cirrhosis    109 

enteritis  of  children 83 

meningitis    339,  341 

pulmonary  edema   217 

Rocky    Mountain   fever 588 

typhoid 479,  480,  484 

variola    542 

Stuttering,  in  mouth  breathing. ..  .191 

spinal  ataxia    370 

tic  419 

(See  speech) 

Subacidity  of  gastric  juice 23 

Suffocative  catarrh 212 

Sugar  in  blood,  diabetes  mellitus.  .280 
Suicide,  in  aortic  regurgitation. ..  .166 

hydrophobia  531 

pellagra    334 

Summer  complaint 82 

Sunstroke    316 

Suppurative  encephalitis   389 

Supermotility,  of  stomach 34 

Suppurations,  in  cholera 576 

glandular  fever 565 

erysipelas    516 

in  broncho-pneumonia 213 

Suprarenal    capsules,    disease    of.  .306 
Swallowing,  discomfort  after, 

cardiospasm   32 

Swallowing  painful,  tetanus 532 

(See  dysphagia) 

Swelling,  around  jaw,  mumps 562 

Swelling  of  face,  in  acute  nephritis. 249 


Sweating,  excessive,  in — 

acute  articular  rheumatism 518 

appendicitis   97 

arthritis    276,   278 

delirium  tremens   325 

malaria 582 

Malta  fever   572 

perinephric  abscess   260 

plague    529 

rachitis    286 

relapsing  fever   520 

tetanus    532 

tuberculosis    467 

typhoid,  convalescence 480 

typhus,  convalescence 487 

variola    541 

Sweating,  nocturnal,  in — 

exophthalmic  goiter   299 

tuberculosis 467 

Sweating  sickness 568 

Symmetric  gangrene    315 

Syncope,  in  Addison's  disease 307 

anaphylaxis    321 

aortic   lesions    166 

cerebral  anemia    372 

dilatation  of  heart 145 

disease  of  coronary  arteries 150 

fatty  heart   144 

gout 272 

heat  injuries  316,  318 

myocarditis    141 

pulmonary  hemorrhage   215 

local,  Raynaud's  disease 315 

Syphilis   521 

Syringomyelia 360 

Tabes,  diabetic   280 

dorsalis 345 

Tabo-paralysis 349 

Tachycardia  154 

Tape  vi^orms 603 

Tastes,  disturbances  of,  in — 

aura  of  epilepsy 410 

fifth  nerve,  lesion 438 

hysteria    394 

metallic,  lead  poisoning 328 

mercurial   stomatitis    19 

sweet,  diabetes  mellitus 279 

unpleasant,    in    gastritis 42 

Teeth,  abscesses 26 

diseases   25 

grinding,   in   children,   chronic 

entero-colitis    87 

loosened,  scorbutus  289 

mercurialism    330 

notched,  syphilis ,  526 

Temperature,  subnormal  in — 

amebic  dysentery  590 

appendicitis    96 

biliary  colic    1 19 

cardiac  asthma 157 


640 


INDBX 


emphysema 220 

heat  exhaustion 318 

hemorrhage  into  pancreas 123 

oral  with  rectal  pyrexia  cholera. 576 
(See  fevers) 

Temulentia    323 

Tenia— 

conf usa    604 

elliptica    605 

flavopunctata    604 

lanceolata    604 

nana    604 

saginata 605 

solium    604 

Tenesmus,  in — 

amebic  dysentery  590 

colitis    94 

malaria,  choleraic   583 

thread  worms .594 

proctitis    101 

Tenth  nerve,  lesions 443 

Terrors,  at  night 191 

Tetanic  chorea   421 

croup   203 

Tetanus   532 

Tetanus,  after  vaccination 547 

Tetany 303 

Thermic  fever 316,  317 

Trichinosis 597 

Thirst,  severe  in — 

acute  articular  rheumatism 517 

cholera  575 

diabetes  insipidus  283 

diabetes,  mellitus  279 

dysentery 570,  590 

enteritis  91  et  seq. 

fevers,  q.  v. 

poisoning,  food 336-337 

Thomsen's  disease  450 

Thread  worms    594 

Throat,  sore,  in  gastroxynis 34 

Throat,  sore,  in  scarlet  fever 550 

Throbbing,  precordial,  dilatation  of 

heart  145 

Thrombosis 377 

in  pneumonia 505 

Thrombosis,  intestinal   583 

Thrush    18 

Thymic   asthma 203 

Thymus,  persistent   ! 313 

Thyroid,  enlarged,  in — 

acute  thyroiditis   295 

autointoxication    65 

exophthalmic  goitre    298 

simple  goiter   296 

Thyroiditis    acute    295 

Tic,  general   420 

Tics    419 

Tic  doloreaux   426 

Tick  fever 587 


Tinnitus  aurium  442 

in  aortic  regurgitation 165 

autointoxication 65 

caisson  disease   363 

hypertrophy  of  heart 147 

desert  sickness   320 

nephritis    255 

tubercular  meningitis   470 

Toes,  amputation  by  dry  gangrene  568 
Tongue,  coatings,  in  diagnosis....  21 

diseases  of   21 

Tongue,    furred,    white,    becoming 
brown,   in — 
fevers,   q.  v. 

gastro-intestinal   inflamma- 
tions   16  et  seq, 

gout    271 

furred,  thick,  white,  "blanket,"  in — 

acute  articular  rheumatism.  ..Sl7 

itching  of,  geographical  tongue.   23 

red,  coated,   scorbutus 289 

red,  glazed,  diabetes  mellitus. . .  .280 
red  papillae  swollen  through  white 

coat,  scarlet  fever 551 

retracted,  morphinism    2i27 

swollen,  pale,  showing  prints  of 
teeth,  in — 
anemias,  q.  v. 

chronic    gastritis    42 

hypochlorhydria    Zi 

tremulous,  dark,  chronic  alco- 
holism     325 

Tonsillar  secretion,  treponema,  in. 526 

Tonsillitis,  acute 188,  190 

in  acute  articular  rheuma- 
tism    517,  518 

scarlet  fever 550 

Tonsils,   diseases   of 188 

hypertrophy    190 

Tophi   272 

Tormina    59 

acute  colitis 94 

amebic  dysentery 590 

tropical  dysentery   569 

Tormina  ventriculi   34 

Torpid  liver  105 

Tortipelvis    451 

Toxemia,  in  acute  enteritis 91 

Toxic  and   constitutional   diseases. 

Part  VI   270 

Tracheo-bronchitis     205 

Transposition    of    viscera 148 

Traumatic  neurosis   403 

Treatment,  general,  for  cord 

diseases     354 

Trematodes    600 

Trembles   536 

Tremor,  in — 

exophthalmic   goiter 298,   299 

lenticular  disease  387 


INDEX 


641 


lead  poisoning 3^ 

multiple  sclerosis   344 

paralysis  agitans 421 

senility     452 

syringomyelia    361 

toxic  states  452 

Treponema  pallidum  521 

Trichiniasis   ; 597 

Trichonomas    588 

Tricuspid  regurgitation    167 

stenosis    168 

Tropical   cachexia    586 

Tropical  diseases 566  et   seq. 

sleeping  sickness    588 

dysentery    569 

liver    578 

splenomegaly     586 

sloughing  phagedena 567 

ulcer 587 

Trypansomiasis    588 

Tubercles,  structure  of 461 

Tuberculosis    459 

acute    466 

chronic     467 

fibroid    470 

miliary    468 

Tuberculosis  of — 

genital  organs  474 

joints    473 

intestines 460 

kidneys    474 

larynx     471 

lymph  nodes   471 

lungs    466 

meninges 471 

pericardium    474 

peritoneum 472 

after  measles — 

vaccination    547 

whooping  cough  492 

confused  with  blastomycosis.  .  .  .239 

treatment,  general 462 

Tubular  nephritis  249 

Tubular  vision,  hysteria 394 

Tumor  or  tumors,  in  abdomen — 

appendicitis    96 

bladder    268 

cholecystitis   117 

-cystic    gall-bladder    119 

gall-stones    118 

gastric  dilatation    51 

intestinal   obstruction    72-7i 

intestinal  tumors    78 

movable   kidney    261 

pancreatic  cyst    125 

strangulated  hernia   75 

subphrenic  peritonitis 131 

basal  ganglia   389 

brain    387 


Tumor  or  tumors, 

of   cerebellum    389 

fourth   ventricle    ; 389 

heart  149 

mouth 21 

nerves    431 

orbit .239 

pieces  of,  in  stools 77 

in   vomitus    49 

pons    389 

prostate   269 

skin,  psorospermiasis    589 

raspberry  like,  yaws .568 

soft,   syphilis    523 

tumors  of  spleen 313 

(See  also  cancer  and  sarcoma) 

Tunnel  cachexia  598 

Tussis    convulsiva    491 

Tympanitis,  in  acute  enteritis.  .80,  91 

gastritis    42 

typhoid     * 479 

Typhlitis   95 

Typhoid  fever  478 

Typhoid  spine  480 

Typhoid  state,  in — 

cholecystitis    117 

cholera    576 

diphtheria    . . . .- 496 

endocarditis    160 

hepatic  abscess    Ill 

influenza    490 

glanders    536 

malaria    583  et  seq. 

measles   558 

milk   sickness    536 

tuberculosis    469 

trichinosis     •. . . .  597 

tropical  dysentery    570 

typhus    487 

yellow  atrophy    107 

Typhus,  abdominalis  478 

icterode    573 

malignant    487 

Tyrosin,  in  urine,  yellow  atrophy.  107 

Tyrotoxismus    336 

Ulcerative  enteritis  of  children..,  84 
Ulcers — 

follicular    198 

perforating    44 

peptic     44 

syphilitic   198,  2,22,.  522 

tuberculous    198.  472 

typhoid   198,  478 

varicose  178,  179 

Ulcers,  of  anus,  in  sprue 567 

colon,  in  constipation 61 

cornea,  in  fifth  nerve  lesion. ..  .438 

duodenum    44 

ear,  eye,  in  variola 543 

feet,  in  leprosy 475 


642 


IXDBX 


foot,  from  which  worms  escaped, 

dracontiasis 594 

intestines    72,  76,  84 

larynx,  in — 

typhoid 480 

tuberculosis    471 

variola    543 

mouth,  in  typhoid 480 

mouth,  mercurialism   330 

palate,  gangosa  569 

rectum,  proctitis  101 

rectum,  in  syphilis 523 

skin,  Biscra  button    587 

glanders    537 

phagadena 567 

tropical   splenomegaly    586 

stomach    44 

throat,  in  diphtheria 496 

tongue 21 

pertussis    492 

Umbilictis,  induration  around,  can- 
cer of  peritoneum    133 

Umbilicus   prominent,   ascites 129 

Uncinariasis  598 

Unconsciousness,  attacks  of, 

petit  mal  411 

Unconsciousness   in    hydrophobia. 531 
Unconsciousness,  sudden,  cerebral 

hemorrhage   375 

Untruthfulness,  in  morphinism 326 

Undulant  fever   572 

Uremia,   in   cholera 576 

diphtheria   496 

nephritis   250,  255 

Uric  acid  and  urates — 
increased,  in — 

articular   rheumatism    518 

gall-stones     119 

gastritis    43 

Hodgkins'  disease 243 

leukemia 240-243 

periodical  variations  in  gout. 270-273 

uricemia,  gout   272 

Urinary  incontinence,  in — 

epilepsy   410 

spinal  meningitis    341 

Urine,  acetone,  diabetes  mellitus.  .281 
fevers,  q.  v. 

actinom5'cosis    535 

black,  in  malaria 583 

blood,  in — 

bladder  and  kidney 

diseases  247  et  seq. 

gout 270 

malaria 583 

purpura  310 

(See  also  hematuria) 

dark,  hemolytic  anemia 236 

dark,  with  bile,  in  gall-bladder 
and  liver  diseases 104  et  seq. 


diacetic  acid  in,  diabetes 

mellitus    281 

fevers,  q.  v. 

filaria  in    595 

milky,  in  filariasis 595 

odor  sweet,  like  apple-blossoms, 

diabetes   mellitus    281 

offensive,    diabetes    insipidus.  .283 
opalescent,  diabetes  mellitus. ..  .281 
sugar  in  (See  glycosuria) 
Urine,   increased,   in — 

diabetes  insipidus  284 

diabetes   mellitus    281 

fevers,  convalescence,  q.  v. 

hysterical    crisis    v394 

malarial  chill    582 

scanty  or  suppressed,  in — 

ascites    129 

cholera  576 

colitis   94 

enteritis  of  children 83 

fevers,  q.  v. 

gall-stones    119 

gout   271,  273 

morphinism    327 

obstruction  of  bowel 74 

yellow  atrophy   107 

Urticaria,   in   anaphylaxis 321 

hemorrhagic  jaundice .528 

spinal  meningitis    508 

vaccination    547 

Uvula,  edema  195 

Vaccination    * 546 

Vaccinia   546 

general    547 

Vaginitis,   due  to   trichomonas. ..  .588 

Vagotony    445 

Vagus,  in  cardiospasm 32 

Vagus   nerve,   lesions 443 

Valvulitis 158 

Valvular    lesions    '. .  162 

Valvular  lesions,  treatment 169 

Varicella    .*....; 548 

Varicose  aneurysm   175 

ulcers    1 78 

veins 178 

Varicosities    178 

Variola    540 

Varioloid  542 

Varix    :..175,    178 

Vasomotor  disturbances, 

neuralgia    426 

Vertigo   or   dizziness   in — 

aortic   lesions 165,   166 

arsenicism 331 

arteriosclerosis    173 

autointoxication    65 

before  cerebral  hemorrhage  ....375 

brain  tumor   388 

cerebellar  disease  389 


INDEX 


643 


cerebral  anemia    372 

constipation    61 

dilatation  of  heart   145 

fevers,   q.   v. 

gastro-intestinal    diseases. . .  .33-126 

goiter    297 

gout   271 

heat  apoplexy    317 

heat  exhaustion 318 

hypertrophy   of   heart 147 

imperfect  vision    ....*. 437 

Meniere's  disease  442 

migraine 405 

multiple  sclerosis  344 

polycythemia   239 

tropical  dysentery   570 

tuberculosis  469 

Vegetation,  on   cardiac  valves. ..  .158 
Veins,  of  abdomen,  enlarged  in 

ascites   129 

hepatic  cancer  113 

cirrhosis     108 

Veins,  hardening 174 

Ventricles,  hypertrophy  147 

Vertebrae,  erosion,  in  aneurysm. .  176 

Vesical   hemorrhages    267 

Vesical  tenesmus,  in  acute 

prostatitis    .  .' 268 

Vestibular  nerve 441 

Visceral  disturbances,  in  hysteria  394 

Visceral    prolapse    68 

Visceroptosis    68 

Viscosity  of  blood,  in  heat  exhaus- 
tion     318 

Vision,  dulled,  in  typhoid 480 

Visions,  hysteria 393 

epilepsy    '...'. 411 

Visual   cortex,   lesion   of 435 

Visual  disturbances,  in  alcoholism  323 

diabetes  mellitus 280 

hysteria    394 

migraine    405 

nephritis    250,    255 

Visual  fields,  contraction  of,  in 

hysteria    394 

Visual  sensations,  aura  of  epilepsy. 410 
Voice,  hoarse,  in  mouth  breathing.  191 
modified  in  laryngeal 

paralysis  164,  444 

husky,  cholera  576 

leprosy    475 

syphilitic  laryngitis    524 

tuberculous  laryngitis 471 

Volvulus    72-76 

Vomiting,  see  nausea 


Vomitus,  greenish,  later  "rice 

water,"  cholera  morbus 93 

Vomitus,  resembling  coffee 

grounds,    gastric    cancer 48 

(See  hematemesis) 

Voracity,  hysteria    394 

typhoid  convalescence    480 

Walking  typhoid .479 

Wandering   kidney    261 . 

Wassermann,  in  syphilis.  .521   et  seq. 
Wasting,    rapid,    fermental    enter- 
itis of  children 82 

(See   emaciation) 

Water   cancer    20 

Water  hammer  pulse,  aortic 

regurgitation    166 

hemolytic  anemia  236 

Weakness,  an  early  symptom  in — 

Addison's  disease 307 

costogenic  anemia   231   ' 

chlorosis .233 

gastric  cancer   48 

hemolytic  anemia  235 

leukemia    240,   242 

multiple  sclerosis   . . . .  ; 344 

muscular   atrophy    252 

scorbutus    289 

splenic  anemia 238 

tuberculosis    461 

Weil's  disease  528,  566 

Werlhoff's  disease   310 

Whipworm    593 

Whistling,  Bell's  palsy 440 

White  leg,  in  typhoid 480 

WhitloWs,    painless,    in    Morvan's 

disease    361 

Whooping  cough   491 

Widal   reaction,   typhoid 481 

Wildfire 515 

Winking,  tic ." 419 

Winter  cough   .'. 206 

Wool-sorter's  disease   537 

Word  deafness   441 

Wrist  drop  329 

Wry  neck   445 

Xanthopsy,  in  jaundice 105 

Xerostomia   26 

Yawning,  in  chronic  gastritis 42 

Yeasts,  in  blood,  blastomycotic 

anemia   239 

gastric  contents,  gastritis 39 

urine,  cystitis  206 

Yellow  fever   573 

Yellow  jack   573 

Zoophilia , 401 


Publications  of  the 
Education  Department 


Clinical  Osteopathy 

By  Dp.  Louisa  Bums 
Revised  by  Dr.  C.  P.  McConnell  and  a  large  corps  of  editors 

Summary  of  Contents 


Diseases  of  the  nervous  sys- 
tem: General  discussion 
with  reference  to  bony 
lesions  in  etiology  and 
treatment. 

Pnnctlonal  nerTons  disorders: 

The  neurasthenic  states; 
hysteria;  habits  and  occu- 
pation neuroses;  chorea; 
paralysis  agitans;  epilepsy; 
migraine;  Raynaud's  dis- 
ease; angio-neurotic  edema. 

Diseases     of     tlie     peripheral, 

spinal  and  cranial  nerves; 
neuritis,    neuralgia. 

Diseases    of    the    spinal    cord: 

Locomotor  ataxia,  infantile 
paralysis,  syringo  -  myelia; 
myelitis;  meningitis;  mus- 
cular dystrophies  and  atro- 
phies; the  ataxias. 

Diseases  of  the  brain:  Tumors, 
circulatory  cerebral  dis- 
eases; cerebral  inflamma- 
tions; paralytic  dementia; 
the    aphasias. 

Diseases  of  the  ductless  glands: 

Additon's  disease;  status 
lymphaticus;  exophthalmic 
and  simple  goiters;  cretin- 
ism, myxedema;  acromega- 
ly; osteitis  deformans. 

Diseases  of  circulation:  Car- 
diac inflammations;  valvu- 
lar lesions;  cardiac 
neuroses;  angina  pectoris; 
arterio-sclerosis  and  an- 
eurysm. 


Diseases  of  the  respiratory 
system:  The  pneumonias; 
emphysema;  bronchitis  and 
related  diseases,  hay  fever, 
diseases  of  the  nasal  mem- 
branes; pleurisy. 

Diseases  of  digestion:  Stom- 
atitis and  other  oral  dis- 
orders; tonsillitis-  pharyn- 
geal diseases;  adenoids, 
diseases  of  the  esophagus; 
gastric  neuroses;  ulcers, 
cancer;  pyloric  stenosis; 
constipation  and  diarrhoea; 
appendicitis. 

Diseases  of  the  liver:  Jaun- 
dice; yellow  atrophy;  cir- 
rhosis; abscess;  neoplasms; 
diseases  of  the  gall  bladder 
and  ducts;  cholelithiasis. 

Diseases  of  the  pancreas  and 
peritoneum. 

Diseases  of  the  blood:  Chlo- 
rosis, pernicious  anemia, 
costogenic  anemia;  blasto- 
mycotic  anemia;  the  leuke- 
mias. 

General  diseases:  Diabetes 
mellitus  and  insipidus; 
obesity;  pellagra;  rickets; 
scurvy;  malnutrition. 

Bacterial  and  parasitic  dis- 
eases: Tuberculosis;  lep- 
rosy; influenza;  pyogenic 
infections;  typhoid  fever; 
measles,  scarlet  fever,  diph- 
theria, mumps,  smallpox; 
and  other  infectious  dis- 
eases; amoebic  dysentery; 
helminthic  invasions. 


1  be  text  of  this  volume  ■mil  be  reviewed  ty  a  numlier  of  tlie  best  men  in  tlie 
profession,  including  representatives  of  all  tlie  colleges. 

1  nc  metnoa  is  to  em{>liasize  chiefly  diagnosis  and  treatment. 

700  Pages— Price  $4.00.    Subscriptions  are  Solicited 

The  A.T.  Still  Research  Institute 

Administration  Dej^artment 

122  South  Ashland  Boulevard       .*.       CHICAGO,  ILL. 


studies  in  the 
Osteopathic  Sciences 

Basic  Principles 

VOLUME  I 

DR.  LOUISA  BURNS 

This  volume  includes  the  experimental  demon- 
stration of  the  osteopathic  centers  and 
early  proof  of  the  place  of  bony 
lesions  in  causing 
disease 

Summary  of  Contents 

Relations  of  normal  structure,  function,  environment  and  habit; 
relations  of  abnormal  structure,  function,  environment  and  habit;  re- 
lations of  abnormal  structure  to  parasites  and  infections. 

Experimental  demonstrations  of  the  osteopathic  centers  and  of  bony 
lesions  as  a  cause  of  disease;  centers  governing  cranial  structures,  arms, 
lungs,  heart,  abdominal  and  pelvic  viscera. 

Glossary. 

Bibliography. 

288  pages,  illustrated 
Price,  $4.00 


The  a.  T.  Still  Research  Institute 

—  Administration  Department  ^=- 

122  South  Ashland  Boulevard  Chicago,  Illinois 


STUDIES  IN  THE  OSTEOPATHIC  SCIENCES 


The  Nerve  Centers 

DR.  LOUISA  BURNS 

A  study  of  the  physiology  of  the  nerve 
centers,  with  especial  reference  to  the 
causes  of  malfunction  and  the  place 
of  bony  lesions  as  disturbing  factors. 


SUMMARY  OF  CONTENTS 

The  structure,  physiology,  and  relations  of 
neurons.  — The  relations  of  sensory,  motor 
and  association  nerve  impulses.  — ^The  spinal 
centers,  with  especial  reference  to  bony 
lesions  affecting  their  activities.  — The  medul- 
lary, cerebellar,  pontine,  ganglionar  and  cor- 
tical centers,  with  reference  to  causes  of 
disturbed  functions.  — The  nervous  control  of 
the  heart,  blood  pressure,  blood,  and  body 
weight.  —  Table  of  Osteopathic  Centers. 
Glossary.  — Bibliography. 

327  pages,  F2  illustrations       Price  $4.00 

The 

A.  T.  Still  Research  Institute 

ADMINISTRATION  DEPARTMENT 
122  SOUTH  ASHLAND  BOULEVARD.  CHICAGO 


Studies  in  the  Osteopathic  Sciences 

The  Physiology  of 
Consciousness 

Volume  III 

DR.  LOUISA  BURNS 

In  this  book  mental  activities  are  explained 
in  terms  of  neuronic  action.  It  gives  a  basis 
for  more  rational  treatment  of  the  insanities. 

Summary  of  Contents 

Cerebral  Relations 

The  Inhibitions 

Nature  of  Consciousness 

Language 

Relations  of  somatic  and  cerebral  processes,  with 

reference  to   effects    of  mental   states    upon    the 

body,  and  of  bodily  states  upon  the  mind 

Education  in  therapeutics 

Glossary 

Bibliography 

j^2  pages ^  illustrated  Price,  $4.00 

The  A.  T.  Still  Research  Institute 

Administration  Department 
122  South  Ashland  Blvd.  Chicago,  111. 


Puhlications  of  the 
Education  ^e^artnient 

The  Blood 

By  Dr.  Louisa  Bums 

Tnis  volume  incluaes  the  results  or  several 
years  or  researcn,  and  covers  tKe  entire 
subject    in    a    most    comt)renensive    way. 

Summary  of  Contents 

The    Physiology   of  the  cytes    in    disease.      Bloo< 

Blood— Ine aeveloJ)mcnt  J)lates  and  hemoconien. 

of  tKe  blood  cells      PKy-     'j^^  Primary  Anemias- 

sical  changes  in  the  blood  Costogenic  anemia.      Bias 

in     health     and     disease.  4.^^„^^4-*„    „»,^^^^         Tl,. 

_,.      -  .  -  .  tomyeotic    anemia.         1  in 

1  he  hemoglobin.  c.,w^«J««,r  «r,«.«^«o 

®  secondary  anemias. 

The  Morphology  of  the    The   Leukemias  —  Tk* 

Blood— The  normal  ery-  organisms  found  in  the 
tnrocytes.  Trie  erytnro-  blood.  The  blood  serum, 
cytes  in  disease.  Normal  Technique  of  blood  ex- 
leucocytes.      Tne    leuco-  ammations. 

Every  practicing  osteopath 

should  have   this  book. 

350  Pages  Price  $4.00 

A  large  number  of  cuts  and  colored  plates. 


Advance  Suhscri^tions  are  Solicited 


The  A.  T.  Still  Research  Institute 

122  South  Ashland  Blvd. 
Administration  Department  CHICAGO,  ILL. 


Research  Department  Records 

Bulletin  No.  2 

Records  of  Research  Work 

to  June  30th,  1915 

Dr.  J.  DEASON,  Director 

T^venty-five  series  of  exj)eriments  covering  the  work  conit)letea 
under  tne  ausf)ices  of  the  institute  by  Dr.  JDeason,  since  the 
publication  of  Bulletin  No.  1. 

250  pages— Price  $2.00 
Illustratea  oy  cuts  and  half-tones 


Bulletin  No.  3 

Diseases  of  the  Ear,  Nose  and  Throat, 
and  their  Osteopathic  Treatment 

Dr.  J.  DEASON,  Director 

Summary  of  Contents 

J\  Review  of  the  Anatomy  joi  the  Ears,  Nose  ana  Throat — 
Diagnosis  of  Partial  Deafness — Deafness  caused  by  Occlusion  of 
Eustachian  Tubes. 

The  External  Ear — Exercises  for  tke  develot)ment  of  Muscles 
of  the  Pharynx — Tinnitus  Aunum. 

Irrigation  Versus  Antisef)ties  in  tke  Treatment  of  Catarrhal 
Affections  —  Irrigation  m  the  Treatment  of  Hay  Fever  —  Case 
j\,ef)orts — Summary  of  Cases  and  Results. 

130  pages— Price  $2.50 

Illustrated  hy  cuts  and  colored  plates 

The  A.T.  Still  Research  Institute 

Administration  Department 
122  South  Ashland  Boulevard        /.       CHICAGO,  ILL. 


Vuhli cations  of  the 
Education  Department 

Public  Sanitation 

IncluQing  a  series  or  t)at)ers  on  tnis  sub- 
ject, witn  a  few  pa^Qvs  on  otner  subjects 
left  by  tke  late  Dr.  C.  A.  Wkiting. 

Summary  of  Contents 

The  Relation    of    the    Osteo-  Tlie   oyster.      Poison   oak, 

pathic  Physician  to  Public  TypKoid  fever.     HyJropliobJa. 

Health-Hygiene  and  Sani-     j^^^^   ^^^  ^^^^LC  Hy^iene- 

tation.      Disease  germs  outside  Bubonic    plague.       Good   I 


the   human    body.      JJisease  „     i    i      i.i        t^*      „^       L "    L 

.,         f  ■' ,  .      ,  and   health.      Uiseases   which 

germs    outside    oi   the    animal  ^^,,    i       „^ ^^     r^^    ^-ii 

I     ,  j-j  1-^.  may    be    acquired    irom    milk, 

body.      r^rotozoan    JJiseases.  T^    ^  *.  TA/  i. 

rr^,  ^  ^      c    ^•  1  Uegenerates.       Water    as    a 

1  he  sbread   of  disease    by  car-  •        r  i  •  Q  _    „i.   J " 

^  x^-  ,  ^         ,  carrier  oi  disease,     oome  studies 

ners.      Disease    by    bersonal  r  , i        .        '     •    i 

T  c     '      c        c      •     '  °*  *^"®  ofeonic  index, 
contact.    Infection  from  fomitcs. 

Infections  tKrougk  the  air.  Miscellaneous  Chapters— TKe 

human  brain.  The  J)urin  oodies. 
Cleanliness  and  Isolation —  A  hydatid  mole.  TKe  de- 
Failure  of  isolation  in  con-  velof)ment  of  the  epithelial  or- 
tagious  diseases.  Flies  and  gans.  Shall  tonsils  be  removed, 
mosquitoes.  Tajieworms.  Pellagra.  Food  t)reservatives. 
Nematode  worms.  Trematoda  Tuberculosis.  Addiction  to 
or  nukes.  Bed  bugs  and  cock-  drug  habits.  Old  age.  Pre- 
roackes.       Amoebic     dysentry.  servation  of  food  supplies. 

The  only  work  on  this  subject 
by  an  osteopathic  physician. 

350  Pa^es  Price  $3.00 

The  A.  T.  Still  Research  Institute 

122  South  Ashland  Blvd. 
Administration  Department  CHICAGO.  ILL. 


University  of  California 

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405  Hilgard  Avenue,  Los  Angeles,  CA  90024-1388 

Return  this  material  to  the  library 

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M129C 

1917 

McConnell. 

Clinical 

osteopathy 

UCI  CCM  LIBRARY 


